Julie A. Schumacher, Michael B. Madson-Fundamentals of Motivational Interviewing - Tips and Strategies For Addressing Common Clinical Challenges-Oxford University Press (2014)

Fundamentals of Motivational Interviewing
Fundamentals of Motivational
Interviewing
Tips and Strategies for Addressing Common
Clinical Challenges
JULIE A .SCHUMACHER
MICHAEL B.MADSON
1
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Library of Congress Cataloging-in-Publication Data
Schumacher, Julie A.
Fundamentals of motivational interviewing : tips and strategies for addressing common clinical
challenges / Julie A. Schumacher, Michael B. Madson.
pages cm
ISBN 978-0-19-935463-4 (paperback)
1. InterviewingPsychological aspects. 2. Motivation (Psychology) 3. Interviewing in
psychiatry. I. Madson, Michael B. II. Title.
BF637.I5S38 2015
158.39dc23
2014022206
987654321
Printed in the United States of America
on acid-free paper
With gratitude to Scott, Liam, and Levi who support and inspire me every day.
JAS
To Carol and Dave Madson, my colleagues, collaborators, and students.
MBM
CONTENTS
Acknowledgments ix
PART I. Motivational Interviewing Overview
1. Introduction 3
2. Foundational Concepts and Skills 11
3. The Four Processes of MI 42
PART II. Motivational Interviewing for Clinical Challenges
4. Less Ready to Change 71
Clinical Challenge 1:No-Shows 72
Clinical Challenge 2:Non-adherence 80
Clinical Challenge 3:Client Involved in the Legal System 89
5. Loss of Momentum 99
Clinical Challenge 1:Slow Progress 100
Clinical Challenge 2:Lapses and Relapses 107
Clinical Challenge 3:Overly Ambitious Expectations 116
6. Psychiatric Symptoms and Disorders 124
Clinical Challenge 1:Depression 125
Clinical Challenge 2:Anxiety, Trauma-Related, and Obsessive
Compulsive Disorders 140
Clinical Challenge 3:Psychotic Symptoms 153
7. Working with Multiple Individuals 166
Clinical Challenge 1:Parents 166
Clinical Challenge 2:Groups 173
8. Challenges in Learning to Use and Implement MI 188
Training Challenge 1:Clients who Frustrate You 191
Training Challenge 2:Clients Like You 195
Conclusions 200
References 203
About the Authors 214
Index 215
ACKNOWLEDGMENTS
We are forever grateful to Drs. Bill Miller and Steve Rollnick for their commitment to the ongoing evolution of MI and their altruistic generosity for sharing their knowledge with others. Their dedication to MI guides us all! We are
thankful to be a part of the Motivational Interviewing Network of Trainers
MINTand value the energy and discussions about MI among its members. As
researchers, we are honored to have colleagues in the international MI research
community who advance our knowledge of the application of MI through
their critical evaluations. It is through the work of these researchers that the
understanding of MI and evidence of its effectiveness have been generated. We
are grateful to these individuals. In particular, we are thankful to have great
research collaboratorsDrs. Scott Coffey and Claire Lane as well as numerous
students and fellows we have had the privilege of mentoring over the years. Our
appreciation of MI has developed through the various trainings we have provided, clients we have treated, and cases we have supervised. We are thankful
to the students, community providers, and clients who helped us deepen our
knowledge of how to practice and teach MI! It is through our experiences with
each of these individuals and groups that our ability and inspiration to write
this book developed. Finally, we want to acknowledge Margo Villarosa for her
careful review of this book.
PART I
Motivational Interviewing
Overview
Introduction
As described more fully in chapter 2 of this book, motivational interviewing,
or MI, is a communication style that providers can use to help facilitate client
change. If you are new to motivational interviewing and have just begun reading
Fundamentals of Motivational Interviewing: Tips and Strategies for Addressing
Common Clinical Challenges, you are probably asking yourself two key questions:(1)Does MI work?; and 2)How do Ilearn MI? Whether you are a novice or experienced provider of MI, you are probably asking yourself, How will
this book be helpful to me? Here we provide answers to these vital questions
about MI and outline the key features of this book, its intended audience, and
how to use what you learn.
D O ES M OT I VAT I O N A L I N T ERV I E W I N G WO R K?
Although initially developed and written about by Dr. William R. Miller as an

intervention for alcohol use disorders (1983), in the more than 30 years since
the original article on MI was published, MI has been applied successfully
to promote positive change in areas ranging from reducing problem drinking (Vasilaki, Hosier, & Cox, 2006), to weight loss (Armstrong et al., 2011), to
reducing criminal offenses (McMurran, 2009), to utilization of life-saving clean
water technologies in Zambia (Thevos, Quick, & Yanduli, 2000). To say research
on MI has been burgeoning may be an understatement. Lundahl and Burke
(2009) reported that entering the term motivational interviewing into a single research database (PsycInfo) in March 2009 resulted in the retrieval of 707
articles published during the decade from 2000 to 2009! Although the potential
uses of MI are seemingly boundless, it is important that all providers who wish
to use MI are aware of the current evidence supporting (and in some cases failing to support) various applications of MI.
At least four comprehensive reviews of the MI literature using a statistical approach called meta-analysis have been published in the last decade (e.g.,
Burke, Arkowitz, & Menchola, 2003; Hettema, Steele, & Miller, 2005; Lundahl,
Kunz, Brownell, Tollefson, & Burke, 2010; Rubak, Sandbaek, Lauritzen, &
Christensen, 2005). These reviews have statistically combined the findings
4
M o tivati o n al I n t e rvi e wi n g Ov e rvi e w
of numerous randomized controlled trials to draw more robust conclusions

about the efficacy of MI than can be gleaned from a single study. Overall, these
meta-analyses suggest fairly unequivocal support for MI as an intervention for
alcohol and drug problems, especially when compared to things like a wait list,
reading materials, or non-specific treatment-as-usual. For these problems, MI is
generally equivalent but not superior to other specific interventions, although in
some cases MI may require a smaller dose of treatment to achieve comparable
effects (Lundahl & Burke, 2009). These researchers also found emerging support
for MI for improved general health behaviors (e.g., diet and exercise) and health
indices (e.g., cholesterol, blood pressure, body mass), gambling, parenting practices, and safe water use. Support was not found for MI improving emotional/
psychological well-being, eating problems, and HBA1c (an indicator of diabetes
control), though it is important to note that research to date on eating problems and HBA1c is very limited. Mixed support was found for MI as an intervention for HIV risk behaviors and cigarette smoking in the general meta-analyses.
However, recent systematic reviews and meta-analyses focused just on smoking cessation (Heckman, Egleston, & Hoffman, 2010; Hettema & Hendricks,
2011)provide stronger evidence that MI can be efficacious for smoking cessation.
Importantly, while MI research literature is burgeoning, there are several
promising areas of research on MI that are still in their infancy. This is especially
important to note, given ongoing anecdotal evidence we receive as MI trainers,
that MI may be utilized most broadly in some of the areas for which it has the
most limited support. Four such areas are corrections, group therapy, mental
health, and high school counseling. Although MI is widely used in corrections,
a recent review of the literature suggests research supporting this application of
MI remains limited (McMurran, 2009). Likewise, although many facilities and
providers prefer group treatment approaches and offer MI as a group intervention, there is far less research on MI as a group intervention, and the research that
has been conducted suggests that outcomes are not as strong for group-delivered
MI (Lundahl & Burke, 2009; Wagner & Ingersoll, 2013). There is also increasing discussion of how MI might be applied in mental health settings to perhaps
enhance treatment engagement and augment outcomes for cognitive behavioral
therapy for problems such as depression and anxiety (Arkowitz, Westra, Miller, &
Rollnick, 2008; Westra, 2012). In support of those discussions, Lundahl et al.
(2010) found promising evidence that MI impacts non-specific treatment factors, including increasing treatment engagement, increasing client intention to
change, and reducing client distress. However, as Burke (2011) notes, there is
currently insufficient research to support the definitive conclusions that integration of MI with cognitive behavioral treatments does in fact improve mental
health outcomes. Finally, whereas there is compelling evidence for the efficacy
of MI for adolescent substance use and health behaviors (Jensen et al., 2011;
Naar-King & Suarez, 2011), there is little research that MI enhances achievement
or reduces the dropout rate among high school students. Nonetheless, there is
increasing discussion of the promise MI holds for enhancing school achievement and engagement (Atkinson & Woods, 2003; Frey et al., 2011). Given that
Introduction
findings for MI are always emerging and sometimes surprising, providers of MI

are encouraged to stay apprised of the MI literature to ensure that it is applied
where it is useful and avoided where it is not.
H OW D O IL E A R N M I?
Given its broad applicability, it is not surprising that individuals from many
professional disciplines including, but not limited to, nurses, dieticians, physicians, counselors, social workers, psychologists, addiction professionals, probation officers, clergy, battered womens advocates, and laypeople have sought
to learn MI so they can be instrumental in helping others make positive
changes in their lives (Madson, Loignon, & Lane, 2009; Soderlund, Madson,
Rubak, & Nilsen, 2011). The good news is that although individuals from different professional backgrounds may encounter unique challenges in trying to
learn MI (Schumacher, Madson, & Nilsen, 2014) there is evidence that individuals from a variety of backgrounds and professions can achieve equal outcomes when delivering MI (Barwick, Bennett, Johnson, McGowan, & Moore,
2012; Lundahl etal., 2010).
Despite its increasing popularity across disciplines, there is also a mounting
body of research to indicate that MI is not practice as usual nor is it easy to
learn (Miller & Rollnick, 2009). Our combined 21 years experience learning MI,
training countless others from varying backgrounds in MI, and doing research
on MI training is consistent with those conclusions. Although MI sounds familiar and intuitive to many professionals and laypersons alike, for many the practice of MI seems to run directly counter to the strategies commonly relied upon
when helping others discuss important life changes. In fact, what seems to come
most naturally to many we train (and to us, for that matter!) are strategies that
are actually inconsistent with the practices and principles of MI. For example
quickly giving advice when someone mentions a problem they are having (e.g.,
asking, Why dont you try...? or Have you tried...?) or directly confronting
others statements that do not support change we view as necessary or important
for them (even when such confrontations are well-intentioned, as in the case of
telling someone who says I just cant do itYes, you can!).
The amount and type of training necessary to achieve provider proficiency in MI is both uncertain and more extensive than commonly believed.
Although workshops are the most common continuing education model,
research suggests that skill improvements are often not achieved or short-lived
with such training (Walters, Matson, Baer, & Ziedonis, 2005)and may be particularly limited when training is urged or required by an employer (Miller &
Mount, 2001)rather than independently sought by the trainee (Miller, Yahne,
Moyers, Martinez, & Pirritano, 2004). Miller and colleagues (2004) found
that for highly motivated providers (i.e., providers who self-selected and made
expenditures for training) with high levels of baseline skill:(1)2-day workshop training alone produces substantial but non-enduring skill increases;
6
(2)small doses of both feedback and coaching help maintain training gains;
and (3) the combination of feedback and coaching is required to produce
desired changes in client utterances during MI sessions. Close examination
of the findings of Miller et al. (2004) study suggests that a combination of
training, feedback, and coaching was sufficient for most, but not all, providers
to achieve and maintain beginning proficiency in MI, but that few providers
achieved expert competence in MI. Anyone familiar with the general literature on becoming an expert will not be surprised by that finding; becoming an
expert at anything generally requires copious amounts of supervised practice
(Ericsson & Charness, 1994). Importantly, Moyers etal. (2008) built on this
study by examining the training model with providers who had fewer basic
counseling skills and expressed less motivation to learn MI. They found that
for this group only 4.3% to 10.3% of participants metall beginning proficiency
criteria, many training gains eroded by 4-month follow-up, and personalized
feedback and consultation did not enhance outcomes. A study examining
live-supervision revealed similarly that five post-workshop supervision sessions were insufficient for many providers to achieve proficiency (Smith etal.,
2007; Smith etal. 2012).
In our own work, similar findings have emerged. We have found that extended
and accelerated training approaches that incorporated experiential learning activities (e.g., skill practice and real play practice sessions) have resulted
in achievement of beginning MI proficiency by many participants (Madson,
Schumacher, Noble, & Bonnell, 2013). However, participants rarely achieved the
expert level after this training. In contrast, when we received and coded participant work samples and provided feedback and coaching, more participants
approached or reached expert level (Schumacher, Madson, & Norquist, 2011;
Schumacher, Williams, Burke, Epler, & Simon, 2013). Anecdotally, we observed
that it was in these coaching sessions that participants developed a deeper
understanding of MI, its foundational spirit, and how to apply the techniques
and strategies in an MI-consistent fashion.
Thus, the research is very clear that despite the broad appeal and seeming intuitiveness of the approach, development of skill in MI rarely occurs in
the absence of formal training and coaching. Moreover, development of true
expertise in this approach requires a hefty dose of training and coaching for
mosteven those who already have substantial experience in counseling or
psychotherapy (Schumacher et al., 2013). Thus, in the interest of complete
transparency, we would like to state directly that we do not believe that reading this book and applying the suggested principles and skills on their own
are likely to make anyone an expert at MI. MI is a very powerful communication style and therapeutic approach that involves more than simply applying a particular technique to a particular situation (Miller & Rollnick, 2009).
Nevertheless, interventions that involve the selective application of principles
and practices of MI may help improve outcomes, as in the case of screening
and brief intervention for alcohol problems in the emergency department
(DOnofrio & Degutis, 2002).
Introduction
W H AT D O ES T H I S B O O K O FFER?
Fundamentals of Motivational Interviewing:Tips and Strategies for Addressing

Common Clinical Challenges evolved out of our years of experience:(1)conducting MI sessions with clients; (2)developing, implementing, and researching novel applications of MI (e.g., Madson, Bullock-Yowell, Speed, & Hodges,
2008; Schumacher, Coffey, et al., 2011; Zoellner et al., 2011); (3) surveying
expert MI trainers and reviewing the literature about how people learn MI,
which aspects of MI they find most difficult to learn or implement, and which
methods facilitate learning (Madson, Lane, & Noble; 2012; Madson, Loignon,
& Lane, 2009; Schumacher etal., 2012; Schumacher, Madson, & Nilsen, 2014;
Soderlund etal., 2011); (4)providing training and coaching in MI to countless
study therapists, undergraduate and graduate students, addictions counselors, nurses, mental health professionals, allied health professionals, medical
students and physicians, probation officers, and lay volunteers (e.g., Madson,
Landry, Molaison, Schumacher, & Yadrick, in press; Madson et al., 2013;
Madson, Speed, Bullock-Yowell, & Nicholson, 2011; Schumacher, Madson, &
Norquist, 2011; Schumacher et al., 2013); and (5) developing and evaluating
methods to assess MI competency and facilitate coaching (Madson, Campbell,
Barrett, Brondino, & Melchert, 2005; Madson & Campbell, 2006; Madson
etal., 2013). The book was written with the highly pragmatic reader in mind;
the reader who hopes to read all or even portions of this book and come away
with not only knowledge about MI, but an ability to apply the principles and
concepts of MI to their daily work.
The book is organized into two sections: Motivational Interviewing
Overview (Chapters13) and Motivational Interviewing for Clinical Challenges
(Chapters48).
Since the publication of the original article on MI by Miller in 1983 and the
original MI text by Miller and Rollnick in 1991, MI has evolved and changed
(Miller & Rollnick, 2002; Miller & Rollnick, 2013). Although the essential elements remain unchanged, definitions, emphases, and terminology have shifted
over time as researchers uncover more about how and why MI helps individuals
change (Miller & Rose, 2009)and how providers learn MI (Miller and Moyers,
2006). Thus, c hapters 2 and 3 of this book are designed to provide the reader
with a clear, concise, and current description of foundational principles, practices, and processes of MI. In addition, these chapters illustrate key concepts
with vignettes and examples depicting MI-consistent, somewhat MI-consistent,
and MI-inconsistent interactions from a variety of settings (e.g., healthcare, substance abuse treatment, criminal justice, and mental health).
The chapters in this book on how to apply MI to various clinical challenges
(chapters4 through 7)evolved primarily out of our years of experience as MI
trainers with varied audiences. Time and time again, individuals weve trained
and coached in MI have asked for guidance in applying the practices, principles, and processes we are teaching them to various specific clinical challenges.
Although the specifics of the challenging situations in which those weve trained
8
have sought to apply MI vary greatly depending on the setting within which a
particular provider works, their underlying questions are very similar. Questions
such as:How do Iuse MI to involve someone more actively in creating a treatment
plan? or, What do you do when a client tries to get you to do all the work for
them? or,How do you help someone who wont comply with treatment? When we
address these questions with our training audiences and in c hapters4 through 7
of this book, many times the answers are simple:You might try agenda setting or
elicitprovideelicit to help engage the client at the beginning of the session. Other
times the answers are more complex, and may require the provider to change not
only what they say and do with the client but also how they fundamentally think
about the client. Our goal is to provide you with clear advice and suggestions
about how concepts, principles, and skills from MI can be applied to the most
difficult situations you encounter in your work.
Chapter4 addresses how practices and principles of MI can be applied to the
challenge of clients who are Less Ready to Change. In particular, we focus on
the nearly ubiquitous problems of no-shows and non-adherence, as well as special considerations and strategies to enhance engagement of clients involved in
the legal system. The last section may be of interest even to readers who do not
work with legally involved clients, as many clients feel coerced to change by loved
ones, employers, or others in much the same way that legally involved clients do.
Chapter5 delves into the challenges associated with Loss of Momentum. In this
chapter we discuss how MI can be applied to clients who experience slow progress or setbacks (i.e., lapses or relapses), as well as clients with overly ambitious
expectations about how quickly change will progress.
Although c hapter 6 focuses on Psychiatric Symptoms and Disorders, specifically depressive, anxiety, trauma- and stressor-related, obsessive compulsive and
related disorders, and psychotic disorders, this chapter may be of great interest
to nonmental health providersfirst, because psychiatric disorders are highly
prevalent, and thus clients who are experiencing these symptoms and disorders
are likely to present in every setting where MI might be utilized; and second, many
of the challenges related to these symptoms and disorders such as poor concentration, disorganized thinking, and lack of motivation are also commonly observed
in individuals who do not suffer from these symptoms or disorders. In the final
chapter of the section on clinical challenges, chapter7, we address how practices
and principles of MI can be used to address challenges commonly encountered
when Working with Multiple Individuals, specifically parents and groups.
In chapter8 we provide a series of tips and strategies for learning MI that we
have identified over our years as MI trainers. We also describe two challenges we
have identified that seem to impede MI learning and implementation for many
providersnamely, feelings of frustration with difficult clients and assumptions
that what worked for the provider personally (when they stopped smoking, quit
drinking, lost weight, went straight, etc.) is also the best solution for their client.
As noted, there is no quick fix solution for learning MI, but we have found that
following some of the tips and tactics and targeting the challenges outlined in
chapter8 may facilitate learning and implementation of MI for some providers.
Introduction
FO R W H O M I S T H I S B O O K I N T EN D ED?
This book is intended as a resource for individuals interested in applying the

principles and practices of MI to their work (paid or volunteer), helping to guide
others in making positive changes in their lives. It is intended as a resource for
those who are already expert in MI, those who are learning MI, and those who
have no prior training in MI, including students. Those who are already expert
in MI may find the updated review of MI practices, principles, and processes
in chapters2 and 3 to be an efficient way to get up to speed on newer concepts
and terms. Experts may also identify applications of concepts and skills to common clinical challenges (chapters47) that they had not previously considered
in their own work. Individuals with some prior MI training may find the concise
and efficient review of key concepts and practical guidance on how to apply the
skills and concepts to common clinical challenges a useful complement to their
other MI training materials. The MI novice will likely find this book a useful,
easy-to-read introduction to what MI is and how it can be used to improve clinical practice and clinical outcomes across a variety of domains and situations.
Although for those desiring to achieve expert competence in MI, this book is
not intended as a substitute for formal MI training and coaching, even those
without such a foundation will likely find practical and easy-to-implement strategies to common clinical challenges in (chapters47). These chapters may also
serve as a nice complement to the information presented in the most recent edition of Motivational Interviewing:Helping People Change, 3rd edition (Miller &
Rollnick, 2013)or to formal workshop training in MI.
Importantly, across various professional disciplines and even within these
disciplines across various settings, different terminology is used to refer to the
population being served and the individuals who serve them. However, given
the similarities weve noted in working with providers across disciplines and
settings, we have elected to rely primarily on standardized terminology in this
book. Any time we use the term client in this book, we are referring to the
individuals who will receive a motivational interview. Any time we use the term
provider in this book, we are referring to YOU. Whatever your specific job
or role within your organization or agency (whether paid or volunteer), odds
are you have a part to play in helping the individuals you serve make positive
changes in their lives. Although many specific examples of applications of MI
concepts and strategies will be superficially applicable to a particular setting or
population, all examples were selected and written to illustrate concepts that are
relevant to most or all MI providers. Readers are encouraged to read all examples, not simply those that depict interactions that might commonly occur in
their work setting.
As noted by Miller and Rollnick (2013), MI is a compassionate approach that
puts the needs of others above self. Thus this book is not intended for use by
individuals who seek to use its principles and practices to promote their own
self-interest or manipulate others. Depending on the context in which a provider
works and his or her relationship to clients within that context, the providers
10
ability to place the best interests of the client ahead of self-interest or agency
interest can be more difficult to navigate. In our discussion in chapter4 of how
MI principles and practices can be applied to clients with legal involvement, we
provide further discussion and guidance on how providers can compassionately
apply the principles of MI in cases where the client is being offered or required to
participate in services he or she did not seek. As a final note, although many of
the professionals and volunteers we have trained who are also parents or spouses
have reported that using reflective listening and asking open questions (which
are not unique to MI) have improved communication in their personal relationships, MI is not intended for use in personal relationships with spouses, children,
or friends.
H OW TO U S E T H I S B O O K
Whereas MI-novice readers may choose to read this book from cover to cover,
experienced MI practitioners may choose to read only a few relevant chapters.
Whether you have thoroughly read none, one, a few, or all of the chapters in
this book, we have designed the book to be useful as a quick reference. When
you encounter a particular clinical challenge or feel stuck, we encourage you
to flip to the table of contents of this book and read those chapters or sections
most relevant to the challenge you face. For example, if you have a client who
has started to miss appointments and you suspect it may be because he or she
has anxiety about coming to see you, you might choose to read the section in
chapter4 on no-shows and the section in chapter6 on anxiety. However you
choose to use this book, we hope you will find it a helpful guide in how to
apply the practices and principles of MI to help resolve a number of ubiquitous clinical challenges.
Foundational Concepts and Skills

W H AT I S M OT I VAT I O N A L I N T ERV I E W I N G?
Motivational interviewing (MI) was initially described as a counseling

approach based on methods from Carl Rogerss person-centered therapy and
social-psychological principles such as cognitive dissonance and self-efficacy to
help increase client motivation to change problem drinking behavior (Miller,
1983). However, over the past 30years, the definition has become broader and is
applicable to a range of professional disciplines and target populations. In 2009,
Miller and Rollnick redefined MI as a collaborative, person-centered form of
guiding to elicit and strengthen motivation for change (Miller & Rollnick, 2009,
p.137). Miller and Rollnick (2013) recently expanded on this definition to provide a more comprehensive understanding of what MI is for, how it works, and
why you may want to use it. Miller and Rollnicks (2013) expansion includes:
What is MI for? MI is a conversation between individuals, often a provider
and a client, about change. Rather than telling clients what to do, the
MI-consistent provider would collaborate with them in an attempt to
strengthen their personal motivation for change.
Why should you use MI? An MI-consistent conversation focuses on clients
motivations for change and in particular feelings of ambivalence they
have about changing. Although ambivalence about change is commonly
experienced, failure to address such ambivalence can keep a person from
changing (Wagner & Ingersoll, 2013).
How does MI work? By adopting a collaborative partnership with clients,
the MI-consistent provider engages in a conversation about change. In
this conversation, the provider intentionally attends to client statements
about change and intentionally uses communication strategies to elicit
and explore a clients own arguments for changing while minimizing
arguments about remaining the same (Miller & Rose, 2009; Wagner &
Ingersoll, 2013).
There is commonality across all three of these definitions. These commonalities are essential components of any MI interaction and any training or research
related to MI. These common elements include:
12
MI is a particular kind of intentional communication about change.

This communication style can be used whether a provider is offering
counseling, assessment/test feedback, supervision, or consultation.
MI is collaborative. In using MI, the provider is focused on being a
partnerNOT an expert!
MI is evocative. To be MI-consistent, the providers focus is on eliciting
clients motivations and ideas about change versus prescribing them.
W H AT M OT I VAT I O N A L I N T ERV I E W I N G I S N OT
In 2009, Miller and Rollnick attempted to clear up several misconceptions about

MI. In doing so, they developed a list of the common misunderstandings people
have about this approach. Corrections to these misconceptions include:
Motivational Interviewing is Not Based on the Transtheoretical

Model (TTM)
TTM and the accompanying stages of readiness change represent a set of
attitudes, intentions and behaviors related to change that a person may hold
depending on their readiness to change (Connors, DiClemente, Velasquez, &
Donovan, 2013). In particular, the stages of readiness to change (precontemplation, contemplation, preparation, action, and maintenance) provide a framework for thinking about where clients are in the change process (Prochaska &
Diclemente, 1983). Clients at the first two stages of change are not committed
to making change. Aclient who is at the precontemplation stage is not aware of
a need to change whereas the client at the contemplation stage is considering
the pros and cons of changing or not. The client at the preparation stage is putting plans into place to begin changing. Clients at the action and maintenance
stages are actively working to modify a behavior or maintain changes already
achieved.
Early writings about MI linked it to the TTM (DiClemente & Velazquez, 2002;
Miller, 1983; Substance Abuse and Mental Health Services Administration,
1999). Often this led people to think that MI cannot be used without the TTM.
Although MI works well with the TTM and in particular the stages of change, it
is not dependent on them. In particular, MI would be valuable for use with individuals in the precontemplation, contemplation, and preparation stages more so
than it would at the action and maintenance stages (Adams & Madson, 2006).
The TTM provides a way of thinking about how people might approach change
whereas MI provides us with an evidence-based communication approach that
fits well with many theories of change (Naar-King & Suarez, 2011). Although MI
can be used at certain stages of readiness to change, its use is not dependent on
these stages.
13
Motivational Interviewing Is Not a Way of Tricking People into

Doing what They Dont Want to Do
Many individuals we train have commented that MI seems like reverse psychology. The concept of reverse psychology refers to one persons advocacy for a belief
or behavior that is opposite to the one they desire for another person for the
express purpose of manipulating the other into do something they are against
doing. Not only is this not what MI is, the idea is contradictory to:the foundation
of MI, the compassion necessary to practice MI, and the ethical application of
MI (Miller & Rollnick, 2013). In fact, to be MI-consistent, the provider is focused
on the clients own concerns, perception of the problem, motivations and recognizing their autonomy to choose solutions that fit best for them and not the
providers own goals.
Motivational Interviewing Is Not a Technique

You cant MI someone! On the surface MI looks easy, but it is a complex,
planned communication process that requires active and intentional listening
and selection of strategies by the provider. There is also a foundational spirit that
is essential to being an MI-consistent provider. By ignoring this spirit for technique a provider would only be going through the motions, not using MI. We
have observed many trainees go through the motions in trying to implement
MI which resulted in poor client outcomes.
Motivational Interviewing Is Not Simply a Decisional Balance

Decisional balance is one strategy that can be used to elicit change talk. However,
there are a variety of MI-consistent strategies that can be used in MI without ever
using a decisional balance (Rollnick, Miller & Butler, 2008; Rosengren, 2009).
Further, people we have trained and coached have incorrectly believed they were
doing MI when they used the decisional balance while completely neglecting
other MI principles and strategies. Thus, a provider can use a decisional balance
without necessarily being MI-consistent.
Motivational Interviewing Is Not just Client-Centered Therapy or

a Form of Psychotherapy
Madson, Schumacher, and Bonnell (2010) highlighted the similarities and differences between MI and client-centered therapy (Rogers, 1959). We expand
this differentiation by comparing MI to other common psychotherapies to
demonstrate how it differs from these approaches (see Table 2.1). The fact that
MI is a communication style, not a type of psychotherapy, lends to its broad
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Table2.1. Comparison of Motivational Interviewing and Common

Psychotherapies
Feature
PersonCentered
MI
Cognitive
Behavioral
Level of direction Following
Guiding
Directing
Directing
Focus in session
Feelings
Change talk
Cognitions
Behaviors
Form of
psychotherapy
Psychotherapy
Communication style
Psychotherapy
Psychotherapy
Length of contact Long-term
Brief
Brief
Brief
Essential
ingredients
Core conditions
Spirit
Challenging
maladaptive
thoughts/
beliefs
Learning
a healthy
opposite
to problem
behavior
Focus in session
Exploration
Increasing
change
talk and
minimizing
sustain talk
Maladaptive
thoughts
and beliefs
Problem
behaviors
Transformative
element
Resolving
incongruence
Change talk
Learning
Learning
adaptive
healthy
thoughts and behaviors
beliefs
Theory of
personality
Developed
None
Developed
Developed
View of
psychopathology
Incongruence
None
Learned
patterns of
thinking
Learned
behaviors
applicability. This diverse applicability has contributed to the widespread proliferation of MI across different disciplines within and outside mental health and
substance abuse treatment.
Motivational Interviewing Is Not Easy

There is vast empirical support that developing competency in MI entails
practice of skill and coaching to develop basic proficiency (Madson, Loignon,
15
& Lane; 2009; Madson, Schumacher, Noble & Bonnell, 2013; Schumacher,
Madson & Norquist, 2011; Walters, Matson, Baer, & Ziedonis, 2005). In fact,
the current gold standard for MI training involves practice with observation and feedback to develop competency (Miller, Yahne, Moyers, Martinez,
& Pirritano, 2004). Similarly, MI is not simply what you have already been
doing. Collectively, we have spent 21years learning, practicing, training and
evaluating MI. Our evolution involved relearning skills and a mind-set that
was based on but different than what we had learned previously about working with clients. We have found that that our personal MI learning experience
as psychologists is consistent with the learning experience of professionals
across the disciplines that utilize MIcertain communication styles and
attitudes need to adjust to develop an MI-consistent practice (Schumacher,
Madson & Nilsen, 2014).
Motivational Interviewing Is Not an Answer for Everything

MI is not a panacea, and there are times when MI is not appropriate. For instance,
when an individual is actively changing a behavior, you would want to employ
active behavior-change interventions. At times like these MI would be contraindicated (Adams & Madson, 2006). However, it is important to recognize that
behavior change waxes and wanes. Thus, MI can be integrated with other change
interventions at those times (Westra, 2012). In fact, given that MI is a communication style focused on the clients change, it can be successfully integrated
with traditional change approaches such as medication management (Interian,
Lewis-Fernndez, Gara, & Escobar, 2013), case management (Leukefeld, Carlton,
Staton-Tindall, & Delaney, 2012), patient education (Gance-Cleveland, 2007),
and cognitive and behavioral interventions (Naar-King, Earnshaw, & Breckon,
2013)you may currently be using. In fact, a major goal of this book is to help you
learn how you can integrate MI with your current approaches to address specific
challenges you may face in working with clients.
Quick Reference
Motivational Interviewing Is Not
Based on the transtheoretical model
Reverse psychology
A technique
Just using decisional balance
Person-centered therapy
A form of psychotherapy
Easy to learn or use
An answer for everything
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T WO C O M P O N EN TS O F M OT I VAT I O N A L I N T ERV I E W I N G
In 2009, Miller and Rose described a theory of how MI facilitates change

through a combination of relational and technical components. The relational
and technical components of MI are not incompatible but are suggested to be
underlying processes of MI (Madson etal., 2013; Martino etal., 2008; Moyers
& Martin, 2006).
Relational component: Grounded in the client-centered approach of Carl
Rogers, this component includes an empathic, affirming, non-judgmental and
autonomy-supportive counseling style intended to create a safe environment in
which clients can explore their own wishes, fears, and concerns (Moos, 2007).
In other words, the provider avoids imposing an agenda, basing acceptance on
conditions, or arguing with or confronting clients, and instead actively listens
to the clients spoken and unspoken messages in order to remain MI-consistent.
Technical component: Built on the relational foundation, a provider uses
strategies aimed at eliciting clients in-session change talk and decreasing
their sustain talk with the overarching goal of evoking commitment to change
(Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003; Miller & Rose; 2009; Moos,
2007). In other words, the provider works with clients, listens intently, engages
in MI-consistent behaviors, and utilizes strategies that elicit and reinforce client statements about desire, ability, reason, and need to change (Moyers &
Martin, 2006).
THE FOUNDATIONAL SPIRIT OF MOTIVATIONAL INTERVIEWING
The foundation of MI, often called the spirit, can be summarized by four characteristics that need to be present in any MI-focused provider-client relationship.
These characteristics are collaboration, evocation, acceptance, and compassion
(Miller & Rollnick, 2013). These characteristics are necessary for a provider to
successfully use MI and are more important than any specific strategy. In fact,
the spirit of MI is the foundation from which any MI interaction develops. For
this reason we provide further explanation of each characteristic of the MI spirit
with MI-consistent and MI-inconsistent examples.
C O L L A B O R AT I O N
MI depends on a relationship between the client and provider that resembles a

partnership. Instead of directing the client and using the presumed power difference, providers and clients participate in a discussion regarding behavior
change. As such, it is important that providers recognize that they have certain
expertise or experience, and at the same time their clients also have expertise
and experience about themselves and previous change efforts. This collaboration
is a defining point of MI because ultimately behavior change is in the hands (or
17
control) of the client. This relationship is conducive (i.e., facilitative or contributing) to change, not coercive.
Example:MI-Consistent/Inconsistent Collaboration
Client Statement:Look, Ijust smoke a little pot [marijuana]. Idont think
it is that big of a deal, but Ifailed a drug screen at work and they made me
come here. So, Ihave to quit now, even though Idont see anything wrong
with it.
MI-Inconsistent:Pot is illegal and against your work policy. If you want to
stop, this program will get you on track.
This response is considered MI-inconsistent because the provider assumes
an expert/authoritarian role. In this role, the provider is not working as a
partner but is telling the client how it is and how to behave. This response
is more likely to increase discord (discussed later) between the client and
provider, not develop a partnership.
Somewhat MI-Consistent:Youre faced with a forced change to keep your
job and that isnt too exciting for you. Ive told you about our program. How
will it work for you?
This response is somewhat but not completely MI-consistent. The provider
reflects the clients concern about being forced to change and attempts to
elicit solutions from the client. However, the provider still communicates
that the client must figure out how to make the program work, which communicates an expert role.
MI-Consistent:Sounds like you are really frustrated and feel like you are
being forced into changing. Since the circumstances are the way they are,
Iwonder if we can brainstorm and work together to come up with some ideas
on how we can make the most of our time together.
This response is an MI-consistent, collaborative response. Not only does it
acknowledge the way the client is feeling about the session without correcting the client about using marijuana, but the provider adopts an egalitarian
approach asking how the two can best utilize their time. The statement also
communicates that the provider wants to work with the client in best utilizing their time versus imposing an agenda of what to address. Thus, the two
are partners.
E VO CAT I O N
Traditionally, many behavior change approaches tend to focus on determining

what clients lack or need and on filling that gap (e.g., medication, knowledge,
skills). Thus, providers often adopt a prescriptive approach determining what
clients need and telling them how to change. Clients often push back to this
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approach, explaining why it may not work. Rather than engage in that back and
forth, the MI-consistent provider focuses on drawing information out of the client (Miller & Rollnick, 2002). This may include eliciting from clients (1) their
perspective of the problem; (2)why they may want or need to change; (3)how
they would change; (4)personal goals and values; (5)why they may not want to
change; or (6)why they may want to stay the same. While a client may lack the
desired level of motivation, all individuals are somewhat motivated to make
changes and every client has ambitions, values, and concerns. Agoal in MI is to
establish a personal connection between the change focus and what the client
values. By identifying clients aspirations and perspectives, a provider can evoke
from clients their own arguments for making changes. In MI, this is referred to
as change talk.
Example:MI-Consistent/Inconsistent Evoking
Client Statement:Well Im here. My physician said Ineeded to see you about
my diet and exercise before Ihad my procedure.
MI-Inconsistent:It is good you are here. We need to get you on a healthy diet
and exercising each day. Ihave a plan that has been really successful
This is an MI-inconsistent response because the provider does not evoke
anything from the client. The provider also prematurely focuses on a change
target and adopts an expert/authoritarian role. The provider is not attempting to understand any aspect of the clients view of the concern. It is highly
likely that the discussion will evolve with the client explaining why the plan
wouldnt work. Without understanding the client, the provider is likely to
evoke more sustain talk than change talk.
Somewhat MI-Consistent:Thanks for coming in today at the request of your
physician. What things should you change about your diet?
This response is somewhat but not completely MI-consistent. The provider
affirms that the client followed through on the request of the physician in an
MI-consistent fashion. The provider also asks an open question. However,
the specific open question selected by the provider focuses the encounter on
changes in diet in a non-collaborative fashionthe provider chooses what
is important without seeking client input. Additionally, the choice of the
word should communicates that the client has to do something.
MI-Consistent:It sounds like your physician wanted you to see me to work
on your diet and exercise. What are your thoughts about seeing me?
This is an MI-consistent, evocative response as it not only reflects the clients understanding of the referral but it also elicits from the client his/her
own ideas about the consultation. The response communicates that the
clients ideas are the important ones in this conversation. This avoids the
premature focus and assuming an expert role. Responding in this way also
avoids the trap of taking sides. Unlike previous responses, this one does not
align the provider with the physiciantaking sides.
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AC C EP TA N C E
Although not new to counseling or to MI; acceptance has recently been explicitly identified as the third foundational component of MI (Miller & Rollnick,
2013; Wagner & Ingersoll, 2013). Acceptance involves appreciating what the
client brings to the interaction. In MI, an accepting environment helps the client explore all aspects of change. This does not mean that the provider has to
approve of the clients actions or give in to the status quo (Miller & Rollnick,
2013). Acceptance, as outlined by Miller and Rollnick includes four aspects.
Absolute Worth
A basic tenet of person-centered therapy is that every human is trustworthy
and has potential to change and to do the best for themselves (Rogers, 1959).
Recognizing the potential and worth in every client is essential to developing a
solid relationship and communicating acceptance.
Accurate Empathy
To be MI-consistent, a provider has to have a genuine interest in and desire to
appreciate and understand the clients situation. This does not mean feeling
sympathetic towards or identifying with clients. It does mean that MI-consistent
providers actively seek to understand the world of their clients and how that
relates to their change or lack of change. For instance, if a client was not taking her/his medication, a provider would be MI-consistent by seeking to better understand the clients situation, values, and goals to see how they relate to
change versus simply lecturing the client about the need to take the medication.
Accurate empathy communicates that the provider is interested in clients experience and wants to learn what it is like for them.
Respecting Client Autonomy

MI depends, in part, on the providers separation from the clients final decision to make a change. This does not mean that MI-consistent providers avoid
caring about their clients; instead, it implies recognizing that individuals are
responsible for their decision making. This is a difficult concept for many providers to accept. However, we often remind those we train that they do not
follow their clients 24 hours a day, 7 days a week. Clients must make their
own decisions about what they think is best for them all the timeso why
not embrace this fact? Aprovider can offer information, advice, and feedback,
but ultimately, the decision to make a change is on the client. Acknowledging
the clients autonomy to decide often aids in the process of change as they
20
recognize they have the freedom and ultimate responsibility for making
changes how they deem appropriate.
Affirmation
As a strength-based approach to counseling, MI-consistent providers strive
to recognize, comment on, and elicit client strengths and resources (Madson,
Loignon, Shutze, & Necaise, 2009). Most individuals who seek help, whether by
choice or coercion, have likely attempted to change in the past with variable success. Often clients focus on failures at change or thwarted efforts. In affirming
clients, the goal isnt to be a cheerleader or offer positive affirmationsit is to
help clients see their strengths, resources, and previous success from which this
change effort may be built
Example:MI-Consistent/Inconsistent Acceptance
Client Statement:Look at this scar on my face. Idont know why the police
arrested me, Iwas just defending myself. Shes crazy!
MI-Inconsistent: I hear you. An important part of fixing this problem is
accepting responsibility for your behavior. That will help keep you out of jail.
This response is MI-inconsistent because the provider directly confronts
the client. The response conveys that the provider has taken the side of the
clients partner and the criminal justice system, is not interested in hearing
the clients perspective, does not respect the clients right to make choices,
and is critical rather than affirming. It is highly likely that this response
would reduce the clients ability to engage with the provider and use the
interaction to actively consider what types of changes he might need or
want to make in his life.
Somewhat MI-Consistent:You do not believe that the police listened to your
side of the story and are uncertain you belong in this treatment. How can we
ensure you keep out of trouble?
This response is somewhat MI-consistent. The provider resists the righting
reflex and instead reflects the clients perception of the situation. The provider also attempts to evoke potential solutions from the client. However,
there is little effort to communicate the elements of acceptance.
MI-Consistent:You do not believe that the police listened to your side of the
story and you are not certain that you belong in this treatment. Given that
you feel that way, Iappreciate that you kept this appointment and showed up
anyway. Ultimately you will have to decide what if anything you can learn
from this program.
This response is MI-consistent because it conveys that the provider has
heard and is trying to understand the clients perspective on his current
situation, and thus conveys empathy. The response also affirms that the
21
clients willingness to keep his appointment is a strength and acknowledges

that the client has the autonomy to decide what he will do. Taken together,
this willingness to listen to the client, support his autonomy, and recognize
his strengths convey clearly that the provider values the client and recognizes his absolute worth as a person.
C O M PAS S I O N
Compassion is an authentic, emotional response when perceiving others suffering and results in a desire to help (Seppala, 2013). In other words, compassion
includes a sense of responsibility and care for human beings that intensify their
motivation and drive to better their clients lives (Fromm, 1956). Thus, in practicing in an MI-consistent fashion, it is essential to always have the best intentions
for your clients and genuinely care about their welfare. However, it is important
to avoid the righting reflex (discussed later) as a result of concern for the welfare
of and wanting to do good for others.
Example:MI-Consistent/Inconsistent Compassion
Client Statement:Isnt there anything you can do to save my foot?
MI-Inconsistent:We have been working with you for years to try to get you
to better manage your blood sugar. Im sorry but at this point there is nothing
we can do. Hopefully this situation will help you better manage your diet and
medications in the future so you dont also lose your other foot.
This response is considered MI-inconsistent, and might well represent
a response from a provider who is experiencing burnout. Although the
response contains factual information that addresses the question asked by
the client, it does so in a confrontational fashion and without compassion
for the clients current state of emotional distress and need for comforting
and reassurance as well as information.
Somewhat MI-Consistent:You are very upset about losing your foot. What
can you take from this situation about how to avoid future losses?
This response is somewhat MI-consistent. The provider reflects the clients feelings and attempts to elicit rather than confront the client.
However, the client may experience the response as judgmental and
non-compassionate given the focus isnt on relieving the pain but how
the client can learn from this experience.
MI-Consistent: I can tell you are very upset about losing your foot, and
Iwish there was something Icould recommend that would save it.
This response is an MI-consistent, compassionate response because it conveys empathy with the clients current emotional distress as well as a desire
to resolve that distress. This response may open the client up to using the
provider as a source of emotional support during a difficult life transition
22
and to working with the provider to try to better manage his or her diabetes
in the future.
Quick Reference
Foundational Motivational Interviewing Spirit Components
Entering into a collaborative working relationship
Eliciting from clients versus prescribing to them
Appreciating client worth and autonomy, affirming strengths, and empathizing with their situations
A sense of care and responsibility for the welfare of clients
FO U R G U I D I N G PR I N C I PL ES
Although not included in some of the most recent writings on MI (e.g., Miller
& Rollnick, 2013), in our work as MI trainers, we have found that the four guiding principles of MI, as elaborated by Rollnick, Miller, and Butler (2008), help
many providers improve their grasp of the foundational spirit of MI. These principles are (1)resisting the righting reflex, (2)understanding and exploring the
clients motivations, (3)listening with empathy, and (4)empowering the client
and encouraging hope and optimism. It can be helpful for providers to remember the acronym, RULE:Resist, Understand, Listen, and Empower in relation to
remaining MI-consistent.
R:Resist the Righting Reflex

Providers tend to want to heal pain, make things right, and endorse well-being.
Thus, when providers witness someone making poor choices, they have a strong
urge to try to stop the individual or set them in the right direction. This
motivation is what makes the desire to correct someones behavior an automatic reflex (i.e., righting reflex). However, providers who give into the urge to
correct often experience the opposite of what they hope to achieve. Instead of
choosing to change a behavior when they are told to do so, clients often resist
change, particularly when they sense persuasion. This is not because clients
are lazy, contrarian, or even in denial concerning their need to make a change.
Instead, people are naturally inclined to push back against anothers attempt
to influence their behavior (Leffingwell, Neumann, Babitzke, Leedy, & Walters,
2007). This push-back is particularly powerful when someone is experiencing
ambivalence (i.e., feeling two ways about the same thing) toward a behavior.
For example, overeaters often are aware that their eating is problematic, and
23
they are often aware of some of the negative consequences of their eating. At
the same time, these individuals enjoy food, recognize the role food may play
in socialization, and do not want to see themselves as having an eating problem. Instead they would rather see their eating as normal. Thus, these individuals often simultaneously feel two ways about their eating behaviorboth
for and against changing it.
When clients see providers taking sides with the healthy part of the clients
ambivalence, making a case for why they need to change, their natural response
will be to make an argument against making a change (Leffingwell etal., 2007).
Consequently, the providers reflex may be to make a stronger argument, which
will likely cause a client to argue more. Because people have a tendency to believe
what they hear themselves say, a providers arguing with a client may actually
be solidifying the clients argument against making a behavior change. In MI,
the client should be the one who is making a case for change, not the provider.
Because many clients are ambivalent about making changes, it is the providers
job to help them work through this ambivalence and aid them in making a case
for a change. To be MI-consistent, a provider needs to understand ambivalence
as a natural part of change and not as pathological. This stance helps providers
avoid educating or persuading clients to changeresisting the righting reflex.
Therefore, MI-consistent providers use a variety of strategies to highlight and
explore client ambivalence, including questioning, simple and complex reflections, affirmations, and summaries (Miller & Rollnick, 2002).
Example:Resisting the Righting Reflex
Client Statement:Look, Iwish everybody would just leave me alone about my
HIV. Iget what they are saying about needing to stay on top of my treatment
and sexual behavior, but Ifeel fine and all my friends have unprotected sex.
MI-Inconsistent:You dont seem to be as worried about your HIV as everyone else. Dont you think it is important to address?
What about trying to always have a condom with you in case you have sex?
These two provider statements are MI-inconsistent and illustrate two different ways the righting reflex can manifest itself in working with ambivalent clients. The first statement directly confronts the clients ambivalence
as denial in a direct attempt to get the client to reconsider his or her perspective. Likely this statement will engender discord between the client
and provider. In the second statement, the provider succumbs to offering
unsolicited advice and prescribes a solution. It is likely that the client will
respond by discussing how the solution will not work.
Somewhat MI-Consistent:You recognize that change is hard and also recognize that others have concerns about your HIV and believe that you may
need to change your behavior. It seems important to keep yourself and others
safe in the future.
24
This response is somewhat MI-consistent. The provider provides a nice

double-sided reflection that highlights the clients ambivalence. However,
rather than simply highlighting the ambivalence, the provider attempts to
resolve it for the client by siding in favor of change. The client is likely to
respond with talk about not changing.
MI-Consistent:You recognize that change is hard and also recognize that
others have some reasonable concerns about your HIV and believe that you
may need to change your behavior. Tell me where this all leaves you.
The provider is reflecting the ambivalence the client obviously feels about
making changes to his or her HIV-risk behavior. This helps convey to the
client that the provider understands his or her dilemma and is not judging
the client. By following up with a Tell me statement that invites the client
to explore further why he or she might consider reducing HIV-risk behavior, the provider actively works to help client resolve ambivalence.
U:Understand the Clients Motivations

Each client has reasons for making a change, and those reasons will be more likely
to persuade them to change than your reasons (Neighbors, Walker, Roffman,
Mbilinyi, & Edleson, 2008; Rollnick etal., 2008). Being interested in a clients own
motivations and values is an important part of eliciting from clients and increasing
their motivation to change. Because consultation time with each client is limited,
this may sound unreasonable and like a waste of time. However, as previously outlined, the provider voicing of reasons for change can actually be counterproductive
and cause the client to voice arguments against change. Thus, from an MI perspective, your limited time is better spent asking clients why they are interested in
making a change than telling clients why they should change. This principle again
is focused on the client voicing the reasons for change, not the provider.
L:Listen to the Client

MI requires listening to clients with empathy in order to understand their reasons
for making a change. Although providers are often viewed as the experts on a
subject (e.g., good nutrition, medication, behavior change), typically answers to
questions involving how and why change will occur for a particular client come
from the client. The skill of listening is essential for gathering these answers.
E:Empower the Client

When clients take an active role in the decision-making process and feel empowered to make a change, the outcomes are typically more positive and changes are
25
often made. While providers may be knowledgeable regarding specific aspects

of changing such as how to diet, take medications, manage anxiety, and how
change will improve the clients life, the client is the expert on how to fit the
change into his or her daily life. Therefore, a client will likely know how to best
accomplish the goal of change. In this process, it is the providers role to offer
support of the clients belief that he or she can make a change and to help the client feel comfortable sharing his or her expertise in the consultation.
BAS I C M OT I VAT I O N A L I N T ERV I E W I N G S K I L LS
Basic counseling skills are vital to interactions across several helping professions
from medicine to corrections. In MI, these basic counseling skills are used intentionally and purposefully during the course of an interaction in order to facilitate client discussions about changing (change talk) and to minimize discussions
about not changing (sustain talk). In other words, providers can use these basic
counseling skills to elicit and selectively reinforce client discussions in favor of
changing and to guide clients away from discussions related to not changing. The
skills emphasized in MI are represented by the acronym OARSOpen questions, Affirmations, Reflections, and Summaries (Miller & Rollnick, 2013).
Open Questions
The appropriate use of questions is an important aspect of MI. Providers must
be mindful in sessions to avoid the question and answer trap. This trap is a client/provider interaction in which the provider overuses questions (often closed
questions) and the client simply answers the questions with limited responses.
This trap results in a question-after-question and answer-after-answer process that prevents a deeper discussion of the topic (Miller & Rollnick, 2002).
MI-consistent providers avoid trying to ask more than one question in a row to
avoid this trap!
Open vs. closed question:Aclosed question implies or requires the client to
give a one- or two-word answer (e.g., yes or no) and is used to gather specific
information (Hill & OBrien, 1999; Seligman, 2008). An open question is broad;
encourages clients to talk about thoughts, feelings, behaviors, and/or experiences;
and give clients flexibility in how to respond (Hill & OBrien, 1999; Seligman,
2008). In MI, the use of open questions is preferred to closed questions as open
questions are more eliciting and invite clients to provide more information than
closed questions.
Example:MI-Consistent/Inconsistent Questions
Client Statement:I cant seem to remember to take my evening medications.
MI-Inconsistent Closed Questions:
26
Have you been following your diet?

Dont you think it is important to take your medications?
These questions are MI-inconsistent, and not simply because they are
closed questions. The first question is not in sync with what the client is
talking about and could communicate that the provider is not listening or
does not care about the clients concerns. The second question, while on
topic, is a rhetorical question that could appear judgmental to the client
and engender discord.
Somewhat MI-Consistent Closed Questions:
Have you thought about setting an alarm as a way to remind yourself?
Do you use a pill organizer to help you keep up with your pills?
These closed questions are not as MI-inconsistent as the prior examples, but
are also not fully MI-consistent. Although the provider is not directly giving unsolicited advice about how to improve medication adherence, which
would clearly be MI-inconsistent (Miller & Rollnick, 2013), the provider is
using these closed questions as an indirect way to give such advice.
MI-Consistent Closed Questions:
How long have you had this difficulty?
Do you have difficulty taking your other medications?
While these are closed questions, they are MI-consistent as they are attempting to elicit from the client his or her thoughts about the problem and avoid
prescribing a solution or placing judgment on the situation.
MI-Inconsistent Open Questions:
How can Imake you understand the importance of taking your medications?
How has your diet been?
These questions, while open, are MI-inconsistent. With the first question,
the provider seeks to directly confront the client about medication compliance, which is MI-inconsistent. The second question is not in sync with
what the client is discussing and thus shows a lack of collaboration and
empathy.
Somewhat MI-Consistent Open Questions:
What will help you remember?
What are your thoughts about using a pill-minder to help you remember?
These questions, while open and inviting the client to talk, are not fully
MI-consistent. The first question immediately attempts to identify solutions
and a plan for changing. It is not fully MI-consistent as it doesnt consider
client motivation for changing or not. There is a potential for the discussion
to quickly evolve to the point at which the provider offers solutions and the
client rejects them (i.e., righting reflex). The second question is used to elicit
the clients reactions; however, the question is focused on the providers
27
solution, rather than eliciting solutions from the client. Thus the provider is
using the question as an indirect way to offer unsolicited advice.
MI-Consistent Open Questions:
What concerns you about taking and not taking your medications?
What exactly happens in the evening?
What are some reasons you want to take your meds?
These questions are MI-consistent because they invite the client to talk and
they elicit the clients expertise about the situation thus allowing providers
to gain a better understanding of the clients motivations and concerns. In
fact, a question like the third question is likely to elicit change talk (discussed later)an important aspect of MI as it relates to increasing motivation. The first two questions will help the client discuss concerns associated
with medications and barriers that might need to be addressed to enhance
motivation for changing.
Affirmations
When clients are attempting to change, it is common to focus on the problem
or past failed attempts. Correct use of affirmations is a method through which
client strengths can be emphasized. Affirmations, in MI, involve actively seeking to uncover, recognize, and discuss client strengths and positive actions
(Hohman, 2012; Pirlott, Kisbu-Sakarya, DeFrancesco, Elliot, & MacKinnon,
2012). To accomplish this, a provider may comment on a strength, attribute, skill, or action; reframe an action, situation, or attribute in a positive
light; or elicit affirmations from the client. Using affirmations does not mean
a provider acts like an overzealous physical trainer or cheerleader, but that
the provider genuinely elicits, recognizes, and comments on client strengths.
Therefore, affirmations should focus on the client, should not be praise, and
should avoid using the word I as in I approve. In the helping professions, it
is common for providers to use comments like that is good/great or I am so
proud of you. There is no doubt in our mind that these comments are meant
to be supportive; however, they are not fully MI-consistent as they violate
these rules.
Example:MI-Consistent/Inconsistent Affirmations
Client Statement:My family says Iam depressed but Iam not sure. Igo to
work and socialize. Dont depressed people just sit at home and sulk.
MI-Inconsistent:You are depressed and not sure what to do about it.
Although this is a nice example of a simple reflection (discussed later),
it focuses solely on client weaknesses and problems. Thus, there is little
attempt to recognize or comment on strengths. Additionally, it has the
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potential to engender discord between the client and provider as the client
has communicated uncertainty about being depressed.
Somewhat MI-Consistent:Your family thinks youre depressed but depressed
people do not behave the way you are. Iam happy you still came in.
This statement is an example of a good reflection of content. However, the
provider misses an important opportunity to affirm the client by commenting on strengths, successes, or positive behavior. Further, the provider by using I puts the focus on her or his approval versus the clients
inherent strengths or abilities.
MI-Consistent:
Comment on positive action:You came here at the request of your family
even though you are unsure if it is needed. You must care a lot about them.
Reframe situation:You are feeling depressed and are coping with it pretty
well. Youre still able to work every day and go out with friends.
Elicit from client:What sets you apart from those people who sit at home
and sulk?
Each statement is an MI-consistent affirmation as they follow the rules outlined earlier, focus on strengths, and are likely to engage the client in further discussion versus engendering discord between the client and provider.
The first statement acknowledges that the client is uncertain about having
depression yet highlights the care for family members resulting in coming to
the appointment. The second statement reframes the clients focus on sitting
home and sulking to focus on the strength of being active. The third statement elicits from the client qualities that can be used as strengths in changing.
Reflections
As the primary basic counseling skill used in MI, reflections are important as
they help bridge the meaning between what the client is communicating and
what the provider hears, and allow providers to check their understanding of
what was said (Passmore, 2011; Rosengren, 2009). It is important to note that
when offering a reflection, the tone of voice is just as important as the words
uttered. To reflect, the voice should inflect down at the end of the statement. An
up-inflection at the end of the statement, which seems to come most naturally
to most people we have trained in MI, communicates a questiona closed question. To be MI-consistent voice tone should also be devoid of inflections that
convey sarcasm, hostility, or condescension.
Reflections are valuable as they can (1) help demonstrate that a provider is
listening, (2)express provider empathy, (3)communicate an understanding and
appreciation of the client, and (4)help the provider guide the client to a deeper
discussion of the topic. For these reasons, it is also important to avoid tagging
on a question such as Right? or Is that correct? Those types of questions can
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convey to the client that the provider does not really understand them and must
check-in frequently in order to follow them. Reflections should also be used
intentionally in MI to strategically reflect sustain talk, discord and change talk
as providers seek to guide clients toward change. The goal in using reflection
with discord is to join with the client rather than confront him or her about their
ambivalence toward change. When intentionally reflecting discord, a provider is
continuing to understand and foster an engaging working relationship (Miller &
Rollnick, 2013). Change talk is a key aspect for facilitating change in MI, and as
such the MI-consistent provider reflects change talk in an attempt to reinforce
and strengthen it (Miller & Rollnick, 2013).
An MI reflection is categorized as simple or complex.
Simple Reflections
Reflections that remain very close to what the client said, adding little additional
information, are simple reflections (Moyers, 2004). Simple reflections are often
used to acknowledge and validate what the client is saying (Rosengren, 2009;
SAMSHA, 1999). Thus, simple reflections may include statements about basic
client feelings and thoughts or session content. Sole reliance on simple reflections
can slow progress of the discussion to more meaningful aspects of the clients
concerns. Often when our trainees felt their sessions went around in circles with
little progress, we found that they relied mainly on simple reflections and didnt
deepen the discussion.
Example:MI-Consistent/Inconsistent Simple Reflections
Client Statement:My wife bugs me about eating healthy. Icant believe she
made me come here.
MI-Inconsistent:Your eating is bad.
This reflection is MI-inconsistent because it negatively labels the clients eating and is likely to engender discord. The reflection prematurely focuses on
the eating behavior and misses the clients message about being upset over
being forced to come to the session. This missed opportunity to reflect the
clients concern could slow engagement and the development of the working relationship. Instead, the client could become defensive about his eating
behavior.
Somewhat MI-Consistent:Sounds like you and you wife are having some
difficulties.
This reflection is somewhat MI-consistent. It is a reflection of the session
content but is likely to focus the discussion on the clients wife or marital
relationship. Thus, the discussion may end up off moving away from the
potential change target and may lose focus.
MI-Consistent:You cant believe youre here.
This reflection is MI-consistent because it focuses on the message communicated by the client. By reflecting the content of the statement, the provider validates the clients comment and is more likely to foster trust and
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engagement. The reflection communicates that the provider hears where

the client is coming from and that his situation is appreciated. Therefore,
this reflection is less likely to engender discord.
Complex Reflections
Complex reflections are an important ingredient in helping to facilitate client
change within the framework of MI because they expand on the discussion.
Complex reflections are provider restatements of session content, and client
thoughts and/or feelings with substantial emphasis or meaning added to facilitate movement toward positive change (SAMHSA, 1999).
Types of Complex Reflection
Double-sided Reflection: The double-sided reflection is often used in MI.
A double-sided complex reflection occurs when the provider restates a client
statement that captures both sides of ambivalence (Miller & Rollnick, 2002).
Thus, use of double-sided reflections helps to bring to awareness the ambivalence
the client is experiencing without siding one way or the other.
Example:MI-Consistent/Inconsistent Double-sided Reflection
Client: I know people want me to completely stop smoking, but I am not
going to completely quit.
MI-Inconsistent:Smoking is good and you dont want to quit.
The providers response is a nice reflection of sustain talk. However, it is
not an MI-consistent, double-sided reflection because it does not capture
both sides of the clients ambivalence. The reflection only focuses on why
the client wants to continue smoking. This could result in the client talking
further about not quitting.
Somewhat MI-Consistent:You are aware that others are concerned about
your smoking and at the same time are not ready to quit smoking completely.
In this reflection the provider captures both sides of the clients ambivalence. However, it is somewhat MI-consistent as the second half of the
double-sided reflection focuses on not changing. Given that clients are
likely to pick up the conversation where providers leave off, this client is
likely to talk more about continuing to smoke instead of changing smoking behavior. Although an expert-level MI provider might sometimes
intentionally structure a double-sided reflection in this way, generally
speaking this is not the most MI-consistent ordering.
MI-Consistent: You are not ready to quit smoking completely, and at the
same time you are really aware that others are concerned about your smoking.
In this reflection, the provider captures both sides of the clients ambivalence,
recognizing the concern about smoking and the lack of readiness to quit. Thus,
both sides are reflected back to the client without an emphasis on either. There
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are two important nuances in this reflection. First, notice the use of and versus
but when using a double-sided reflection as it emphasizes feeling two ways. Next,
notice that the side of ambivalence related to changing is presented last. This
point highlights one of the intentional aspects of MI. People often continue to
talk about the most recent thing another person states. Thus, the client is more
likely to continue talking about reasons to change because the provider ended
the double-sided reflection with the pro-change side of the ambivalence.
Amplified Reflection:This type of complex reflection occurs when a provider
restates what the client has said, but in a stronger or even more extreme fashion
than what the client communicated (Miller & Rollnick, 2002; SAMHSA, 1999).
Amplified reflections are particularly helpful in responding to client sustain
talk as it amplifies the clients communication about not changing beyond what
the client is saying, yet does not confront or challenge it. When using amplified
reflection, it is important to remain supportive and avoid a tone that could be
perceived as judgmental or condescending as this could engender discord.
Example:MI-Consistent/Inconsistent Amplified Reflection
Client:I dont understand why my wife is so concerned about my cholesterol.
My results suggest it is borderline high, not high.
MI-Inconsistent:You really dont have any problems whatsoever.
This amplified refection is MI-inconsistent for two reasons. First, we highlight
the potential tone of the word really as this could be perceived by the client
as judgmental. Avoiding qualifiers such as this might reduce that perception.
Second, using whatsoever could be perceived as sarcastic and confrontational and could communicate that the provider does not believe the client.
Somewhat MI-Consistent: Your wife shouldnt have any concerns about
you.
In this reflection the provider is amplifying the clients statement. However,
the statement is a more global statement about the clients relationship with
his wife versus an amplified statement about the change target. The client may
respond with discord or the conversation may drift off topic and lose focus.
MI-Consistent:Your wife is worrying needlessly about your cholesterol.
In this reflection the provider is amplifying the clients statement about his
wifes concern by adding the word needlessly. By adding this word the
provider is taking the clients statement to an extreme that the client may
actually disagree with and correct the provider.
Summaries
Summaries fall on the advanced end of reflections. In essence, summaries are
provider statements that pull together and synthesize a group of client statements. To put it in the metaphorical terms of one of our non-MI passions (making
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Southern barbeque):if reflections are individual spices, then summaries are the
exquisite spice rub that pulls all of the individual flavors together to give your
barbeque just the right taste. Summaries can be used to begin and focus a session, close a topic, conclude a session, connect session content, and/or help a
client reflect on what he or she has said (Ivey & Bradford Ivey, 2003; Seligman,
2008). Summaries are valuable to discussions about change as they allow clients
to hear multiple aspects of their conversation all at once. In MI, you use summaries to selectively attend to key concepts (i.e., change talk) when choosing
what to include. Three different types of summaries have been discussed and are
described here.
Example:Summaries
Provider Question: If you were to be successful in making the changes to
your drinking weve talked about, what would be different in your life a year
from now?
Client Statement:Well, if Imake it through this DUI [arrest and conviction
for driving under the influence of alcohol] and get my license back, Id have
a job again.
Provider Response: So one thing is that youd be able to get a job again.
What else would be different?
Client Statement:Well, this isnt really a change from now, but it is a change
from beforenow that Idont go to the bars, Im spending more time with
my kids. Doing homework, eating dinner with them; you know, just normal
family stuff.
Provider Response:So being a more involved father is something youve been
doing and you think would continue a year from now. What else might be different if you were successful in changing your drinking?
Client Statement:Im not sure. Iwould hope maybe Id be able to quit smoking. Ive tried to quit before, and going to bars always makes me want to
smoke. Iguess if Ididnt go to bars maybe Icould quit smoking.
Collecting Summaries: These are summaries that reflect information
gathered over a period of time that are intended to simply continue the
conversation (Rosengren, 2009). In essence, the provider is recalling
several things a client recently stated. We have discussed with trainees
that collecting summaries can be a great way to remain MI-consistent in
intake or assessment sessions as they communicate the provider is listening and enable probing for more information about a topic without simply
asking questions.
Example:MI-Consistent/Inconsistent Collecting Summaries
MI-Inconsistent:So you recognize the way your behavior has damaged your
family both financially and emotionally and you plan to finally be a responsible father and provider.
This summary is MI-inconsistent because it not only summarizes the clients statements, but it also labels the clients behavior in a negative way that
does not convey acceptance.
Somewhat MI-Consistent:So you hope to have a job. You also said youd
like to quit smoking. Am Ihearing you correctly?
This response is somewhat MI-consistent as is summarizes pieces of the discussion. The focus of the summary is on the two things the client wants to
change without including the benefits of the changes discussed by the client.
Thus, this summary may or may not promote positive change. The provider
also uses a closed-ended question to check the accuracy of the summary.
MI-Consistent:So one thing you hope would be different a year from now
is that you will have a job. You have been spending more time with your
kids and want that to continue. You also said youd like to quit smoking and
you think that might be possible if you arent drinking at bars. What steps
have you already taken toward making the changes in your drinking that will
make all of those things possible?
This summary is MI-consistent, because it pulls together what the client
has said without labeling or judging what has been said, and it also focuses
on the elements of what the client has said that are most likely to promote
positive changes in the clients drinking.
Linking summaries: When a provider wishes to connect information
expressed by a client with previous information, a linking summary can be
used (Rosengren, 2009). In using linking summaries the provider is intentionally trying to bridge different things the client has stated.
Example:MI-Consistent/Inconsistent Linking Summaries
MI-Inconsistent:In looking through your chart, Isee that this is your fourth
time in treatment. Icant believe you are still getting DUIs and going to bars
almost every night. You need to get your act together and take treatment seriously this time.
This summary is MI-inconsistent because it confronts the client about his
drinking behavior and also blames him for past treatment failures.
Somewhat MI-Consistent:So it sounds like a lot would be possible if you quit
drinking, including smoking cessation. Im glad to hear that you are considering
smoking cessation now. Thats a big change. Ican see from your chart that youve
declined smoking cessation counseling the last several times it has been offered.
This summary is a somewhat MI-consistent linking summary. The provider uses a summary to link something the client has just said to information from the clients treatment record. However, the summary is not fully
MI-consistent, because the provider shifts the established focus of the session from reducing alcohol consumption to smoking cessation.
MI-Consistent:So you think a lot of important goals, like getting back to work,
spending time with your kids, and quitting smoking might be possible if you were
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to make changes to your drinking. This sounds similar to the way you turned
your life around when you left the gang to join the military when you were 18.
This summary is MI-consistent because it links what the client has just said
about making changes in his drinking to comments he made about other
successful behavior changes, in a way that is likely to promote the clients
sense of self-efficacy about the current behavior change.
Transition summaries:The intention when using a transition summary is to
shift between topics or to change topics (Rosengren, 2009). Transition summaries can be particularly useful during data-gathering interviews such as
intake or diagnostic interviews as they communicate that the provider is
listening and they help ease into the next aspect of the interview.
Example:MI-Consistent/Inconsistent Transition Summaries
MI-Inconsistent:So it sounds like this DUI was finally the wake-up call you
needed. Youve recognized that your drinking is destroying you and your family. Admitting you have a problem is the first step. How long have you been
drinking?
This provider utterance is MI-inconsistent. With the summary, the provider
twists the change talk the client has offered in a very negative, confrontational, and labeling way. The provider then transitions to asking structured
questions without informing the client about the shift or asking permission
to make the shift. Thus the provider controls the direction of the session is
a very non-collaborative fashion.
Somewhat MI-Consistent:Just to summarize, you seem clear on wanting to
stop using alcohol. Now let me go ahead and ask you some questions for our
intake form.
Although this provider statement, in some sense, captures the essence of the
conversation with the client up to that point, it is also not a summary. It does
not bring together two or more distinct ideas expressed by the client. The
provider also misses the opportunity to support client autonomy and maintain a collaborative spirit by asking permission to segue to the intake form.
MI-Consistent:Before Iask you the questions Imentioned earlier, let me
summarize what youve told me so far, and see if Ive missed anything important. You have decided to stop drinking because you have experienced your
third DUI and have faced some stiff penalties. You also imagine that life will
be much different, in a good way, if you are successful in making that change
in your drinking.
Although not as detailed as the collecting summary, this MI-consistent
summary is a true summary in that it brings together two or more distinct
ideas expressed by the client. It is MI-consistent because it does not seek to
judge or label the client, but rather to emphasize those elements of what the
client has said that will help promote change.
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Quick Reference
Basic Motivational Interviewing Skills
Use open questions to invite discussion.
Elicit, look for, comment on, and affirm client strengths and successes.
Intentionally use simple and complex reflections to expand the change
discussion.
Deliberately use collecting, linking, and transition summaries to talk about
change.
C H A N G E TA L K A N D S U STA I N TA L K
Because a major focus of MI is helping clients explore their own reasons for
making a particular change, the MI-consistent provider selectively listens
for and reflects client utterances that favor changechange talk. Miller and
Rollnick (2013) outlined four components of motivation that are reflected in
change talk:(1)wanting to change; (2)perceived ability to change; (3)identified
reasons to change; and (4) importance of that change. Change talk has been
classified into two categoriespreparatory change talk and mobilizing change
talk (Miller & Rollnick, 2013). Preparatory change talk includes statements that
communicate the client is thinking about changing yet the statements by themselves do not predict client action (Amrhein etal., 2003; Carcone etal., 2013).
This type of change talk is represented by the acronym DARN (Desire, Ability,
Reasons, and Need).
Examples of Preparatory Change Talk

Desire
We often emphasize that desire statements are valuable because really wanting
something to be different is important for a client to increase their willingness to
act on it. In fact, wanting, wishing, or desire to change is a major component of
motivation (Miller & Rollnick, 2013). Desire statements may include:
I wish my health was better.
Id like to be calm when Idrive.
I want to go out with my friends and make healthy eating choices.
I want to leave the house without having to check the lock 10 times.
Ability
Client expressions of what they can do or have done before are valuable statements about the clients perceived ability to change What better way is there
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to help clients identify solutions to a problem than hearing and reflecting their
statements about what they can do or have done in the past? Thus, ability statements are important as they communicate what clients have done and what they
are likely willing to do to change. Ability statements may include:
I could probably use a designated driver more often.
I may be able to go for a 10-minute walk each evening.
I can get a pill box to sort my medications.
I might be able to brush my teeth first thing in the morning.
Reasons
A common form of change talk often expressed by clients is the reasons to
change. It is key to elicit and understand why it is important that a client changes
because it is the clients reasons, not others, that will facilitate client change and
are essential in MI. Reason statements often communicate an if...then message. Reason statements may include:
If Ipaid attention more to my son he wouldnt get into as much trouble.
It seems like Iwill have more energy if Iget more sleep.
I want to be able to enjoy things again.
By not smoking Iwould save money.
By talking more to people Imight get more friends.
Need
Clients statements that express the importance of the change reflect how necessary and urgent it is. Miller and Rollnick (2013) highlight that need statements
do not include why the change is important and if they did, the statement would
reflect a reason and not a need. Need statements may include:
I need to do something about my anxiety.
Ive got to stay out of trouble for the rest of the year.
I must lower my blood pressure.
I cant keep gaining weight.
I have to get out of the house and socialize more often.
Quick Reference
Change Talk
Desire:Iwant to change something.
Ability:Ican do this to change.
Reason:If Ichange then this will happen.
Need:Ihave to change.
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Mobilizing Change Talk

Mobilizing change talk, or mobilizing statements, include client statements that
communicate their commitment to and willingness to change and/or the steps
they are taking already to change. This type of change talk can be thought of
using the acronym CAT (Commitment, Activating, and Taking Steps) (Miller
& Rollnick, 2013). Commitment statements are those that express some level
of intention to make a change and are most predictive of change (Ajzen &
Albarracin, 2007; Amrhein et al., 2003). Clients may express varying levels of
intention to change ranging from a very low level (I might try it.) to a very high
level (Im definitely going to do it!). Some clients will discuss the steps they are
making to prepare for change. This has been referred to as activating change
talk (Miller & Rollnick, 2013). Finally, some clients will discuss things they have
already done to change. Statements about steps the client has already taken are
called taking steps (Miller & Rollnick, 2013). Samples of mobilizing statements
may include:
Commitment
I guess Icould try eating whole wheat toast for breakfast.
I will probably increase my walking to 5,000 steps a day.
I am not going to smoke in the car or during the middle of the night.
I am never going to drink again.
Activating
I will call the job center to see when Ican have an appointment.
I plan to buy a pedometer tomorrow.
My wife and Iplan to talk about how to help our son meet his probation
requirements.
I got some information about different social clubs in town.
Taking Steps
I got rid of all of the alcohol in house.
I am now only smoking outside.
I bought some fruit at the store yesterday.
I met with the job coach yesterday.
Quick Reference
Mobilizing Talk
Commitment:Iintend to do this.
Activating:Iam going to do these things.
Taking steps:Idid this.
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Eliciting and Responding to Change Talk

The focus on eliciting and responding to change talk is arguably the aspect
of MI that makes it most distinct from other counseling approaches and
communication styles (Houck, Moyers, & Tesche, 2013; Westra & Aviram,
2013). When practicing MI, providers respond with interest in client change
talk both non-verbally and verbally because provider behaviors have been
linked with client change talk (Glynn & Moyers, 2010). Providers can use
reflections, questions, affirmations and summaries to elicit and reinforce
change talk.
Questions to elicit change talk:What might you need to do differently about
your diabetes?
Asking for elaboration:Tell me more about that.
Reflecting change talk:Its not good, you think, for you to get as drunk as
you do.
Summarizing change talk: What you seem to be saying here is that there are
several reasons you need to change your eating: to feel better, have more
energy, and to be a better model for your children.
Affirming change talk:It sounds like you have thought about this for some
time and know you need to do something about your depression.
S U STA I N TA L K A N D D I SC O R D
Related to the righting reflex mentioned earlier is sustain talk and discord.
Change talk is client speech in favor of change, whereas sustain talk is client
speech expressing desire, reason, and need to remain the same and perceived
inability to change (Miller & Rollnick, 2013). In other words, when articulating
sustain talk, clients are telling you why they should not change.
Sustain Talk Example

Client Statements:
Desire:I want to keep eating the way Ido now.
Ability:I cant turn down a buffet.
Reason:All of my friends eat the same way Ido.
Need:I dont need to change my diet.
MI-Inconsistent:Well you have gained 20 pounds in the past 6months.
This is MI-inconsistent because it is a confrontational argument for change.
Statements such are this are likely to engender discord between providers
and clients. Further, the client is more likely to discuss why the provider is
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wrong in her response, thus becoming more entrenched in staying the way
he or she is.
Somewhat MI-Consistent:Why might you want to change your eating now?
This response is somewhat MI-consistent as it is an open question that intends
to elicit change talk (i.e., reasons to make a change). However, as a response
to sustain talk this question is less MI-consistent as it might engender discord
and increase sustain talk. More specifically, this question dismisses client sustain talk and communicates the provider has taken sides with change.
MI-Consistent:
Simple reflection:Your eating is not a concern for you right now.
Amplified reflection:This concern about your weight is an overreaction.
Double-sided reflection:Your diet is not of concern to you, and at the same
time you chose to come to meet with me.
Reframing:It would be difficult for you to make changes to your eating because
you like food and its an important part of your interactions with friends.
Emphasizing autonomy:Ultimately, it is up to you what you decide to do or
not do about your eating.
These responses are MI-consistent because they are less likely to engender
discord between providers and clients. In fact, each of them communicates
that providers are joining clients where they are at in relation to the area
where change is being considered. Thus, by responding to sustain talk in a
MI-consistent way, providers are more likely to engage clients, reduce the
discord, and open the door to explore change.
Discord
While sustain talk is client communication about a particular change, say changing a diet, discord is more about the relationship between a provider and client.
In other words, discord is a signal that the provider and client are not on the
same page and that there may be a rift in the working alliance (Miller & Rollnick,
2013). Thus, sustain talk and discord should be cues for providers to change their
behavior and respond differently to the client. We often try to emphasize with
those we train that when discord develops it is their responsibility to get on the
same page with their clients to resolve it. To do this, a provider avoids arguing
with the client, listens more carefully, changes direction, and responds to the
client in a non-confrontational manner that attempts to change client energy
toward discussing positive change (Miller & Rollnick, 2002).
Example:MI-Consistent/Inconsistent Responding to Discord
Client Statement:Well, Ireally dont know why Iam here. Iwas in the wrong
place at the wrong time and got an MIP [minor in possession of alcohol].
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I dont understand why they are so upset; everybody drinks on game day.
Icame here because the Dean told me to, but Ireally dont feel like Ishould be
here, but Iwant to stay out of trouble. Now Ihave to come here and hear you
lecture me about how Ineed to change my drinking.
MI-Inconsistent:If the Dean is concerned enough to ask you to come here,
you must have a problem with your drinking.
This statement is MI-inconsistent because it directly argues with the client
in favor of change. This statement is likely to engender increased discord
and will place the client in a position to defend him- or herself and explain
why his or her drinking does not need to change. Not only is the client not
talking about change based on this response, the client will be less engaged.
Somewhat MI-Consistent:If youd like, Ican provide you with more information about the rationale behind the alcohol policy.
This response is somewhat MI-consistent. The provider is asking permission to provide information to address the clients statement that she does
not understand why she has been referred for help. Although asking permission to give information is an MI-consistent strategy, in this case it is
unlikely that the clients concern is really that she does not understand the
alcohol policy. It is more likely that she is frustrated and feels singled out.
Thus this response is unlikely to decrease discord.
MI-Consistent:
Apologizing: Im sorry you were not given clear information about the
policies.
Simple reflection:It seems like you and the Dean have a different view of the
situation.
Amplified reflection: The University is really overacting here about your
drinking given that all college students drink.
Double-sided reflection:You really dont feel like you need to be here and at
the same time you want to learn how to stay out of trouble.
Affirmation:You have really thought through this situation.
Shifting focus:You are concerned Im going to force something upon you.
Idont know enough about you yet to even start talking about what makes
sense for you to do. Id like to discuss your thoughts about what brought
you here a bit.
Emphasizing autonomy: You feel forced to come here and Id like you to
know that it is your choice what to do with the information we discuss in this
program.
All of these statements would be more likely to reduce discord between
providers and clients as they communicate I appreciate your situation and
dont want to force you into anything. Additionally, these statements demonstrate a change in direction to avoid increasing discord. Further, the client
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may be more likely to respond with change talk, reduced push-back, and
more willing to discuss the situation as well as more openness to provider
feedback.
Quick Reference
Responding to Sustain Talk and Discord
Reflect clients concerns about not changing.
Affirm the strengths in clients sustain talk and discord.
Validate clients concerns and shift the focus of discussion to a less contentious
topic.
Explicitly comment on clients autonomy and personal choice.
C H A P T ER S U M M A RY
Our focus for this chapter was to introduce you to MI and provide a brief
overview of the foundational components of this communication approach. In
providing this overview we emphasized the importance of adhering to the MI
spirit in order to develop proficiency. It is from the spirit that the MI-consistent
use of basic counseling skills such as open questions, affirmations, reflections,
and summaries emerge, as well as ones adherence to the principles of MI.
Thus, if one embraces the spirit of MI it becomes second nature to resist the
righting reflex and understand clients motivations through listening to and
empowering them. Adopting the spirit of MI as part of your philosophy can
assist you in intentionally using MI skills and strategies to elicit and reinforce
change talk as well as conceptualize and successfully work with sustain talk
and discord. We hope that we impressed upon you the importance of adopting the spirit of MI in order to continue on your journey of developing your
MI abilities.
The Four Processes of MI
Recent developments in the evolution of MI have moved away from the

two-phase approach to MI (i.e., building motivation and consolidating commitment; Miller & Rollnick, 2002) toward four overlapping processes that
make up MI-consistent interactions. The four processes are engaging, focusing, evoking, and planning. While the processes build on each other, they
are not exclusive; there is not a defined beginning and end to each process
(Miller & Rollnick, 2013). In other words, once a client is engaged, that does
not mean providers can stop attending to client engagement. The conceptualization of the processes that unfold during a motivational interview has gotten
more detailed to enhance clarity about what exactly occurs during a motivational interview. However, in our experience, the actual practice of MI has
not changed. The portion of an MI session formerly termed building motivation for change encompassed the engaging, focusing, and evoking processes.
Similarly, the portion of an MI session formerly termed consolidating commitment to change largely comprised what is now termed planning. In fact
the MI-based interventions we have developed map on to the four phases quite
well even though they were designed prior to the redefinition. The decision to
redefine the two-phase approach into four processes helps to better clarify the
nuances involved in a MI session (such as engaging and focusing) that were
not captured by the two phases. This new approach also has promise to help
providers utilize MI more effectively.
EN G AG I N G
The main focus in the engaging process is on developing the solid working relationship with clients that is important to most clinical encounters
(Horvath, 2001). To do this, a provider must be aware of the importance that
first impressions have on clients and be mindful of how provider actions influence others. In particular, providers must be cognizant of how their actions
affect the perceptions and willingness of clients to enter into a working relationship with them. Helping clients feel welcome, comfortable, and safe to
43
explore their questions and concerns about change are important goals of
engaging. To be MI-consistent in engaging requires avoiding traps such as
those outlined in the quick reference box (Miller & Rollnick, 2002). All of
these are traps because they may lead clients to feel less welcome and safe in
the relationship with a provider.
Quick Reference
Traps to Avoid
Question and answer:Asking too many closed questions.
Premature focus:Narrowing in too quickly on what to change.
Taking sides:Identifying the problem and prescribing a solution.
Expert:Communicating that you have all of the answers.
Engaging clients is vital to MI and is foundational to the other MI processes
and outcomes (Boardman, Catley, Grobe, Little, & Ahluwalia, 2006; Catley
et al., 2006; Moyers et al., 2005; Murphy, Linehan, Reyner, Musser, & Taft,
2012). Thus, an MI-consistent provider is always vigilant to engagement and
signs of disengagement. These signs of disengagement may include the client providing short or vague responses, passively agreeing with suggestions, a
closed body posture, changing the topic, interrupting the provider, or simply
not saying anything.
Miller and Rollnick (2013) suggest that to appropriately engage someone in
an MI interaction requires using a person-centered style that is welcoming,
accepting, and genuinely focused on wanting to understand clients concerns
or problems as well as their values and goals. This requires focus on the person
and listening as opposed to determining the root of the problem and the solutionremember in MI that is not the providers job. Think of an experience
you had with a helper that made it difficult for you to trust them. What was it
about that experience or the persons behavior that made it hard for you to trust
them? Were you open to their help or suggestions? Would you go back? These
are thoughts that clients have when they first meet a provider and are things all
providers should be mindful of to be MI-consistent.
Quick Reference
Motivational Interviewing Training Tip:Signs of Disengagement
Signs of disengagement may include the client providing short or vague responses,
passively agreeing with your suggestions, a closed body posture, changing the
topic, interrupting you, or simply not saying anything.
44
MI-Consistent Strategies for Engaging Clients

OARS
Use of the most basic strategies in MI, OARS (open questions, affirmations,
reflections, and summaries), can be very valuable during the engaging process. These are some examples of the use of each type of OARS utterance for
engaging:
MI-Consistent Engaging Open Questions
How are you?
What are your thoughts about being here today?
In your mind what does our work together look like?
What are your doubts/concerns about being here?
MI-Consistent Engaging Affirmations
Thank you for coming in today. Alot of clients cancel on rainy days.
It is good to see you again. It is impressive how much you are sticking with this.
Looks like you have been making progress.
It couldnt have been easy to make it here today and shows your perseverance.
MI-Consistent Engaging Reflections
Client:[looks at watch]/Provider:The wait was a bit long today.
Client:Are my results in?/Provider:Youre anxious to get your test results.
Client:How long will this take?/Provider:Youre in a hurry.
MI-Consistent Engaging Summaries
So you are really sticking with this and making progress. You made it in even
though it was raining, you were in a hurry, and the wait was longer than usual.
Lets go ahead and jump into those test results.
Exploring Goals and Values

Developing an appreciation for a client is an important aspect of an MI-consistent
approach. One way to appreciate clients and their situations is to learn about their
goals and values. Before a provider and client can discuss changing, it is important for the provider to understand the context that led the client to seek help
and to consider personal change. Exploring goals and values is an interactive
process where the provider guides the client through visualizing and articulating various objectives related to the positive changes they seek. Similarly, exploring values involves the clarification of the clients personal values, or aspects of
life that the client finds particularly important. Clients are much more likely to
work towards a goal that is valued. Therefore, making the connection between
clients articulated goals and values can be critical in their level of engagement
and building motivation for change.
45
Common Phrases/Statements in this Strategy

Exploring goals and values can be introduced to the client in an open-ended
interview format. Most often, a provider starts with broad, open-ended questions like, How would you like your life to be five years from now? or, What
things are most important to you? These questions will begin the process of
engaging and exploration and can lead the client to think about change at a
high level. The order in which the client discusses their different values helps
the provider better understand their relative importance to the client. As clients begin to explore goals and values, reflections of feelings and restatements
can be beneficial in prompting the client to elaborate on or move forward
with a train of thought (for example, So having financial stability for your
children is very important to you, or, You seem a little uncertain about your
ability to order a salad instead of something fried when eating out.) This also
serves to confirm goals and values with the client, allowing them to give the
feedback to the provider concerning how well their goals and values are being
understood.
Motivational Interviewing Trainer Tip: Indications that You Are
Doing MI-Consistent Engaging
You spend the first few moments (or as long as it takes) getting to know the client and putting him or her at ease rather than jumping straight to business.
The client will seem to feel comfortable talking to you!
You will feel comfortable talking to the client.
You and the client are working together.
You will be asking open, not closed questions.
You will be reflecting what you hear the client say.
You are developing an understanding of your clients and their concerns!
FO C U S I N G
Although a motivational interview should not proceed until a client has been
engaged, MI is much more than engaging a client and creating a safe environment for the client to discuss his or her concerns. MI, like many evidence-based
approaches to behavior change, is focused on helping clients make changes
that solve the problems or address the concerns that led them to seek services.
Providing MI involves focusing on what needs to changethe change target.
Thus, the MI-consistent provider guides the client to identify what he or she
wants to change and avoids prescribing or forcing a particular focus. Miller and
Rollnick (2013) suggest that focusing helps to identify the clients change agenda.
Table3.1 provides several examples of MI-consistent questions that can be used
to help clients focusing on change targets.
46
MI-Consistent Focusing Strategies

Table3.1. MI-Consistent Focusing Questions
Question
Why MI-Consistent
What changes might you like to make? These questions can center clients on why
they are seeing you, and build rapport.
What is worrying you most about
?
What concerns you most about
changing your
?
This question can help providers better

understand the clients attitude, behavior,
and where the problem lies for them.
What exactly happens when you try to Questions like this can help providers
?
better understand the clients concerns,
including potential barriers and resources.
What did you first notice about
?
Questions like this can be helpful in

guiding the client to share their expertise
about their experience.
Agenda Setting
Agenda setting is a good strategy for avoiding the premature focus trap.
MI-consistent agenda setting involves a brief discussion with a client during which
the client assumes as much decision-making freedom as possible. This helps the
provider and client determine what topics are important to discuss (Rollnick,
Miller, & Butler, 2008). Aclients willingness to listen to a providers ideas increases
when the provider listens and attempts to truly understand the clients view of
the situation rather than focusing solely on their own concerns (Mason & Butler,
2010). However, depending on professional discipline and the practice environment, providers may have information they must deliver or topics they must to discuss. For instance, through training dieticians, we learned that they often receive
orders from a physician to provide nutrition education, such as a heart-healthy diet
for a patient who recently had a heart attack. These trainees would ask us How can
we allow the client to help set the agenda when we have a specific task to complete?
Our response to this question was that although these requirements may influence
the nature of MI-consistent agenda setting, they do not preclude the possibility
of MI-consistent agenda setting. We encouraged the dieticians to use a guiding
style and look at agenda setting as a shared and collaborative process. As a good
guide, it is important for the dieticians to share the doctors concerns and recommendations and to invite the client to express his or her own concerns during the
agenda-setting process. Agenda setting can be used at various times throughout a
motivational interview when a provider wants to engage the client in active decision making about the direction the interview will take.
< 80mmHg
Men < 40
Diastolic Blood
Pressure
Waist
Circumference
(inches)
18.524.9
Varies
Varies
< 200 mg/dL
< 100 mg/dL
Men > 40 mg/dL

Women > 50
mg/dL
Body Mass Index
Weight
Height
Total Cholesterol
LDL (Bad)
Cholesterol
HDL (Good)
Cholesterol
Women < 35
< 120mmHg
Systolic Blood
Pressure
Healthy Range
1st Numbers 2nd Numbers 3rd Numbers
4th Numbers
5th Numbers
Know Your Numbers Card
Table3.2. Sample Feedback Form for Agenda Setting
6th Numbers
(continued)
7th Numbers
25g/day
~2 tsp/day
(5 tbs/week)
1,000 mg/day
2 to 3 cups
Y/N and I.D.S.
Diet:Fiber
Diet:Sugar
Diet:Calcium
Diet:Dairy
Med:Blood
Pressure
Med:Cholesterol
Y/N and I.D.S.
Med:Blood Sugar Y/N and I.D.S.
45 cups
Post-meal
Glucose:
< 180 mg/dL
Pre-meal Glucose:
70130 mg/dL
Diet:Fruits &
Vegetables
Blood Glucose
Healthy Range
1st Numbers 2nd Numbers 3rd Numbers
4th Numbers
5th Numbers
Know Your Numbers Card
Table 3.2.CONTINUED
6th Numbers
7th Numbers
49
Examples of Agenda Setting

At this time, if it is okay with you, Id like for us to take a look at the results
from some of the questionnaires you completed last time we met. How does
that sound? [Waits for client response]. As you can see from this form, there
are several things we can discuss. What, among this information, would you
be most interested in hearing first?
What would be most helpful for us to discuss first?
Given that your physician has asked me to do so, Id like to discuss your exercise at some point today, but Ialso wonder what youd most like to learn about.
You can also use an assessment feedback form to assist you in setting an
agenda. An example of a feedback form called the Know Your Numbers
card that my colleagues and I(MM) used in Hub City Stepsa healthy lifestyle interventionis provided as an example (see Table3.2) (Zoellner etal.,
2011; 2014). This form was tailored to meet the needs of the project and
focused on health indicators. Aform such as this can be adapted to meet
various assessment and behaviors. Providers can use the card in agenda
setting similar to this:
This is what we call your Know Your Numbers card. This card will be filled
in each time you come back here. In looking at this card you will see it has
information about your blood pressure....[go through sections, cholesterol,
etc.] and info about where your score falls in terms of health. In reviewing
these different areas, we looked at what would seem most important for you
to discuss. Among these things, which do you think is most important for you
to learn about...whats next...
Doing MI-Consistent Focusing
Your clients have had a major role in developing the agenda for your conversations with them.
You have a good understanding of your clients goals.
You recognize how consistent or different the goals are between you and your
clients.
You and your clients are working together toward shared goals.
E VO K I N G
Traditionally, what has been described as MI can be seen in the process of evocation. After a focus for change has been identified, the MI-consistent provider elicits from clients their own reasons for wanting or needing to make the particular
50
changechange talk. It is this eliciting from clients that helps them identify
and appreciate their own motivations for changing. In essence, the individual is
talking him- or herself into changing. The expert MI provider will generally elicit
multiple motivations (remember DARN [preparatory]-CAT [mobilizing] change
talk from chapter2) for change prior to proceeding with planning. Expert MI
providers also generally seek to elicit change talk that focuses not only on the
history of the problem, circumstance, or behavior, but also on how change (or
lack thereof) might influence the present or future for a client (Moyers, Martin,
Manuel, Miller, & Ernst, 2010). Conversely, the MI-inconsistent provider will
lecture clients about why it is important or why clients need to change. This often
counterproductive effort may actually reduce motivation and increase discord,
particularly when clients are ambivalent (Miller & Rollnick, 2013).
It is important to note that the process of evoking will vary from session to
session depending on the motivators for change that are most salient to a particular client. Furthermore, in keeping with the spirit of collaboration described
in c hapter2, it is always essential that a provider use information and feedback
from the client to guide the flow of an MI session. Nonetheless, in our work
as providers and supervisors of MI, we have found a pattern that commonly
emerges during a well-done evocation process. Usually, it seems most natural
for providers and clients to focus first on negative consequences or problems
a client has encountered as a result of the problematic behavior or life circumstance about which change is being considered. In fact, often when a provider
asks: What brings you in today? the client will spontaneously respond with
one or more negative consequences that he or she has experienced related to the
change being considered. For example:My weight has gotten over 200 pounds
and none of my clothes fit any more, or I got my third DUI [driving under the
influence] and my attorney said that if Ididnt come to treatment Id probably do
some jail time. After the negative consequences or problems have been explored
and elaborated, a provider will often elicit anticipated outcomes of making the
change or not making the change. For example, the provider might ask, If you
are successful in losing 25 pounds, how do you think your life would be better?
or What concerns, if any, do you have about what could happen if you continue
to drink and drive?
MI-Consistent Evoking Strategies

Questions to Elicit Desire, Ability, Reasons, and Need (DARN
Talk)
Desire
What do you want (like, wish, hope) will be different?
Why might you want to make this change?
Ability
What is possible for you to do?
What can/could you do?
51
What are you able to do?

If you decided to make this change, how would you do it?
Reason
What would be some specific benefits?
What risks would you like to decrease?
What are the three most important benefits you see from making this change?
Need
How important is this change?
How much do you need to make this change?
Beware of MI-Inconsistent Questions
It is important to be intentional in the selection of evoking questions. The questions that seem to come most naturally to many of those we have trained (and
presumably came most naturally to us before all of these years of MI practice
and training) are questions that elicit the opposite of change talk:sustain talk.
As described in c hapter2, sustain talk refers to utterances that support staying
the same:Why the client does not want to change. Why the client perceives he
or she cant change. Reasons the client believes he or she should stay the same.
The questions that elicit these utterances from a client are things like, Why dont
you...? or Why cant you...? or Why wont you...?
Readiness Ruler/Scaling Questions

Using a readiness ruler or rating scale can be helpful for eliciting subjective
reports of motivation from clients (Lane & Rollnick, 2009). To assess readiness
for change, an Importance-Confidence Scale ranging from 0 (not at all important/confident) to 10 (extremely important/confident) can assist in describing the
clients developing motivation and may elicit change talk by providing a helpful
perspective about the clients personal dilemma surrounding the desired change.
Although verbal forms of the rating scale are commonly used, using visual forms,
such as drawing a line with numbers marked 1 to 10, can also demonstrate scaling questions. (A sample readiness ruler handout is provided in c hapter7.) The
choice of stem for the readiness ruler/scaling questions (e.g., How important is
it to you...? How confident are you...? How committed are you...?) will
determine which dimensions of readiness for change you assess.
For instance, you can ask the client:
How strongly do you feel about wanting to protect yourself when drinking?
On a scale from 1 to 10, where 1 is not at all, and 10 is very much, where
would you place yourself now?
You can also assess the importance that the client places on a particular
behavior:
52
How important would you say it is for you to increase your safe sex practices?
On a scale from 1 to 10, where 1 is not at all important, and 10 is extremely
important, what would you say?
This type of questioning can also be used to assess how confident or certain
the client is in his or her ability to make a change.
Assessing confidence through scaling questions may be accomplished by asking:
On a scale from 1 to 10, where 1 is Im certain that Icould not, and 10 is Im
certain that Icould, how confident are you that you could engage in pleasurable activities?
Particularly near the end of an encounter, this type of question can also be
used to assess a clients commitment to change, as in the following example:
On a scale from 1 to 10, where 1 is not at all, and 10 is couldnt possibly
be more, how committed are you to your plan for walking 4days per week?
A key component of using the readiness rulers/scaling questions is questioning clients about why they rated themselves a particular number. When using
scaling questions, one very useful follow-up is to ask what makes the number
what it is and not a different number. This answer provides perspective on how
and why change is important for the client. Typically, it should be asked why
the clients selected score is higher than a lower number, because it elicits more
reasons for changing (e.g., What makes it an 8 and not a 5?). Aprovider might
also wish to ask the client what it would take to move him or her to a higher
number (e.g., What would it take to move you from a 5 to an 8?). When it
follows an importance ruler, this question creates an opportunity for the client
to consider potentially undesired consequences of not making a change (e.g.,
I guess if Ihad another heart attack Id have to get serious about exercise.).
When it follows a confidence ruler, this question often provides valuable information the provider and client can use in formulating a plan for change (e.g.,
I think if Iknew my family would support me, Id feel more confident about
quitting smoking.). Without these follow-up questions, a readiness ruler/scaling question may still provide valuable information about a clients level of
readiness for change, but represents an important missed opportunity to evoke
change talk.
Beware of Follow-up Questions that Evoke Sustain Talk
As with the MI-consistent evoking questions described earlier, we have found
that for many of those we train, the follow-up question that comes most naturally is most helpful for eliciting sustain talk or defensiveness. For example, if a
provider asks, On a scale from 1 to 10, how important is it for you to take your
medication daily? and the client responds 5, and the provider follows up with
Why are you at a 5 and not a 10? it is almost impossible for the client to answer
53
with anything other than sustain talk (e.g., I just cant make it a priority now
because I have too many other things going on.). A client may also perceive
an air of judgment in such a question (i.e., that the provider believes he or she
should find it more important) and thus responds defensively. Defensive answers
or answers that the client believes you want to hear also arise if rapport is poor.
Therefore, good rapport and a guiding communication style more accurately
assess a clients motivation for change.
Decisional Balance
The pros/cons decisional balance allows a provider and client to fully consider
change by think through positives and negatives of both changing and not changing (Ingersoll etal., 2002). This strategy is typically used when clients are ambivalent about making a change in their life. This strategy helps a provider guide
clients in making a decision about change. The decisional balance exercise can be
introduced with provision of information about the concepts of motivation and
ambivalence.
For example, a provider might say something along the linesof:
Because most of the things we choose to do have both positive and negative
aspects about them, we often experience ambivalence when we consider
changing. Ambivalence means you have mixed feelings about the same
matter, and those different feelings are conflicting with each other. You
want to do something and at the same time you dont want to do it. When
people are ambivalent, it is difficult to make decisions because it appears
that nothing they do will meetall of their desires. One way to work through
this is to look at both sides of the coin by examining both sides of our feelings at the time. Asample decisional balance worksheet is presented in
chapter7.

Doing MI-Consistent Evoking
You have heard at least one and preferably several of your clients motivations
for changing.
You have a sense of how important change is to your clients.
You have a sense of how confident your clients are about change.
You are hearing and responding to change talk.
You are using questions and reflections to draw out change talk versus providing
change reasons.
You are not the one arguing for change.
54
PL A N N I N G
Developing a specific plan for change and commitment to that plan are
important to guiding the client toward change. Consistent with the spirit
of MI, the planning process should focus on eliciting change ideas, options,
and solutions from clients versus prescribing or directing clients in how to
change. This is an important point. In our experience, those we train often
think that once the motivation for change is secured that they now have
permission to be directive and tell clients how to change. However, to
remain MI-consistent, a provider must continue to recognize that clients are
experts on their own lives and as such tend to have at least some, if not all, of
the solutions to their problems within themselves (Miller & Rollnick, 2013).
Thus, the focus at the planning stage should be drawing these solutions out
from clients and supplementing them with information the provider has
about what has helped others in similar situations, what options are available
to the client, or what the provider would recommend (only when necessary
or when requested by the client). By doing so, the provider not only helps the
client identify a solution that is the best fit for him or her, but also increases
the chances that the client will commit to the solution. Think about it for a
moment. Who knows you better than you know yourself? It is unlikely that
we could provide a better method for you to read this book than you could
develop on your own. We can make suggestions, but ultimately, you will read
this book in a way that is best for you. This same principle applies to changing. As professionals, we all have education and experience with methods for
changing a problem behavior. However, we do not know how these methods
may or may not work for each and every client, but the client knows what
will be more likely to work. We can facilitate a planning discussion through
skillful use of questions, reflections, providing information and options, and
summarizing.
MI-Consistent Planning Strategies

Questions
What do you think youll do?
What would be a first step for you?
What, if anything, do you plan to do?
What do you intend to do?
Exchanging Information
Often during change planning, a client may ask or a provider may feel compelled to provide information about change options. What makes information
exchange MI-consistent or MI-inconsistent is the way in which the information
55
is presented. Traditionally, the information exchange process has been an

expertrecipient approach where the expert shares and interprets the information. This is an MI-inconsistent approach to providing information as it neglects
the clients interpretation of the information, focuses on prescribing information
versus eliciting and fosters passivity in clients. An MI-consistent approach to
providing information facilitates a collaborative and engaging method in which
the client is asked to interpret the information.
One process to provide information in an MI-consistent way is to use the
elicit-provide-elicit approach, which is a cyclical process of guiding clients
through information exchange (Lane & Rollnick, 2009; Rollnick etal., 2008). In
this process, the provider elicits from the client before providing information.
For instance, in sharing information about diabetes, a provider might first ask,
What do you know about diabetes? The clients answer to this question will
help the provider better understand what information the client currently possesses, including what is accurate or inaccurate, and better focus the information
offered. Following this eliciting the provider offers a small chunk of information
about diabetes. After giving some information, the provider asks about the clients understanding/interpretation or reaction to the information. This information exchange process can be very valuable when providing assessment results or
sharing a diagnosis.
Example of Elicit-Provide-Elicit:
Initial eliciting questions:
You have discussed several concerns related to your alcohol use and said
things have to change and you are going to do something about it. What
would you like to learn most about or discuss in relation to changing?
Client response:
All Ive heard from people is that to change you have to go to rehab and spend
a lot of time away from work and family.
Provide information in manageable chunks and focus on the data and not
your interpretation:
You have heard some things about what it takes to change ones drinking
behavior and are concerned about that. If Imight share some information
to add to your understanding, people make changes in different ways. Some
people change on their own; some go to a 12-step group, while others engage
in outpatient counseling services. And yes, some people do go to a facility
for intensive treatment. Based on the information you gave us about your
alcohol use compared to national criteria it seems like outpatient counseling may be the most appropriate place for you to address your drinking
concerns.
Follow-up eliciting question:
What do you make of this information?
56
Discussing a Menu of Options

Presenting a menu of options is an approach to engaging clients in the planning
process. With this approach the provider invites clients to choose the change
strategies that seem best for them from a set of options the provider has prepared
based on his or her expertise, best practice guidelines, etc. At the same time, when
using this strategy in a fully MI-consistent fashion, the provider also encourages
clients to include change ideas that may not be in the prepared set. For instance,
in the following example, which might be used with college students, the menu
has safe drinking behaviors that have been shown to reduce alcohol-related consequences. Note that there are open bubbles on the options sheet that would allow
the client to add additional ideas they are willing to consider or are already doing.
When helping the client identify a behavior change strategy the provider can
open the conversation about change options using the menu (see Figure3.1).
Sample Menu of Options
If youd like we can talk about some strategies you might use when drinking
to reduce the risk of negative consequences. Here is a sheet that includes some
behaviors that other college students from your university use to protect themselves when drinking. This area represents putting planned limits on drinking
(the know your limits picture). This area represents mixing alcoholic and
Protective Strategy Options
Figure3.1 Sample Menu of Options for Safe Drinking Strategies
57
non-alcoholic beverages (picture of water). This area represents the manner in

which you drink (the beer cupsrepresenting beer pong). These areas represent reducing the potential for serious harm (the glass and key and the whos
watching your drink). You will also notice some empty areas. These represent
your ideas that are not represented by the other areas. Based on the drinking
goals you mentioned before, which of these strategies, if any, might you use to
protect yourself when drinking yet meets your goals?
Developing a Plan for Change

The change plan is a concrete road map that the participant can follow in order
to reach their change goals (Naar King & Suarez, 2011). To be effective, the
change plan specifically outlines the (1) behavior to be changed, (2) reminders of the motivational factors, (3)change goals, (4)action plan, in manageable
steps in order toward change, (5)potential barriers, and (6)steps to overcome
those barriers. Typically the change plan is implemented when someone is ready
for behavioral action. Thus, the change plan will be negotiated after enhancing
motivation and commitment to make behavioral change.
Common phrases/statements that are used in this strategy:
Now that we have discussed some aspects of your diet and exercise, what do
you think you want to do about your eating and exercise?
Now that we have come this far, Iwonder what you plan to do?
Table3.3. Components of Developing a Change Plan
Planning Goal
MI-Consistent Question
Important Points to
Consider
Identify the changes the

client wants to make.
What might be some of

the changes you want to
make in your health?
It is important to be
specific and include
goals that are positive
(e.g., wanting to increase
exercise, eat more fruits
and veggies) and not just
negative goals (e.g., stop
eating fried foods).
Highlight the reasons to

change.
We discussed several
reasons for changing
earlier such as [summarize
a few points]. For you,
what are some of the most
important reasons you
want to change?
Important to elicit/
remind the client of
the reasons the client
previous provided.
(continued)
Tabel 3.3.CONTINUED
Planning Goal
MI-Consistent Question
Important Points to
Consider
Eliciting why the client

wants to changethe
change goals.
Tell me about your

overall goals or what you
hope you will achieve by
making these changes.
Goals should be realistic

and achievable.
Identifying what the

client plans to do to
change.
There are a lot of things

you can do to work
toward your goalswhat
are some of the activities
you think you will do to
work toward your goals?
Information and
optionspresented in an
MI-consistent fashion
can help.
Eliciting reasonable first

steps.
Of those activities, what

do you think you can do
first?
It is important to elicit
specific, concrete steps.
In making some of these

changes, what are some of
the first steps?
When, where and how
will these steps be taken?
What can interfere or
derail the plan?
Sometimes it helps to
Remain positive and focus
think of the things that
on identifying how to
may get in the way of your sidestep this interference.
plan.
What could interfere
with this plan and how
can you stick to the plan?
Identify who can help the

client maintain the plan.
Who can support you in

keeping to your plan?
It is important to identify
specific individuals and
how they can help.
Identify how the client

will know the plan is
working.
How will you know your

plan is working?
Identify specific, concrete

indicators of how the plan
is working or not.
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Table 3.3 provides some components of change planning and examples of

questions to ask clients, as well as important points to consider with each component. These components are based on the Change Plan Worksheet developed
for Project Match (Miller, Zweben, DiClemente, & Rychtarik, 1992)and revised
and used by us in several projects.
Doing MI-Consistent Planning
You are aware of a reasonable next step but not imposing it.
You are resisting the urge to give advice or recommendations until you have
evoked solutions from the client.
You are asking permission when providing information, recommendations, or
advice.
You are genuinely open to idea that the best solution for a particular client may
not be the one you would recommend.
O N E R OA D M A P FO R T H E FO U R PR O C ES S ES
As providers begin to attempt to implement MI, one concern that is frequently

expressed during early coaching sessions is a lack of confidence in how to navigate an MI session. In response to this concern, we have developed a road map
for a typical MI session that many of the individuals we have trained have found
helpful as they begin implementing MI (see Table3.4). Although the skilled MI
provider will rely primarily on information and feedback from a client to guide
the flow of an MI session, this road map serves as an aid or crutch for early sessions during which the flow of the session is less intuitive. You will note that the
primary strategies are open question, reflections, and summaries. Although they
may not come as naturally as the questions, it is crucial not to skip the reflections
and summaries.
T H E FO U R PR O C ES S ES O F M OT I VAT I O N A L
I N T ERV I E W I N G:AH E A LT H PR O M OT I O N E X A M PL E
One application of MI that we have been involved with is HUB City Steps which
was an MI-enhanced nutrition and exercise intervention aimed at reducing
hypertension among African Americans. The project involved a three-month
intervention where individuals received in person feedback about their health
status and developed an individualized change plan (Zoellner etal., 2011; 2014).
Table 3.4. Sample Road Map for the Four Processes

Engaging
Ask:How are you doing today?

Reflect the clients response
Focusing
If you have an a priori target behavior, ask permission to focus on

it:If its okay with you, Id like to spend a few minutes talking about
____________.
If you dont have an a priori target behavior, ask:What brings you
here today?
Evoking
Ask:What are the three best reasons for you to ____________?

Reflect all the reasons you have been given
Ask:What other reasons might you ____________?
Reflect the response you are given
Ask:How do you imagine your life would be different if you were
successful in ____________?
Ask:On a scale of 1 to 10, how important is it for you to
____________?
Ask:Why is it a ____________ and not a ____________?
Ask:On a scale of 1 to 10, how confident are you that you can
____________?
Ask:Why is it a ____________ and not a ____________?
Summarize ALL the reasons for change you have heard (use a
double-sided reflection if there is some discussion of reasons for not
changing)
Planning
Ask:What is the next step for you? or What do you think you will
do?
Ask:I know weve talked about this quite a bit already, but what
would you say are the main reasons you want to make this change?
Ask:What are the steps you plan to take in making this change?
Ask:What are the ways other people can help you make this change?
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Ask:How will you know if your plan is working?

Ask:What are some things that could interfere with your plan?
Ask:What will you do if the plan isnt working?
Summarize EVERYTHING you have written on your change plan
Ask:On a scale of 1 to 10 how committed are you to following this
plan?
Ask:Why are you at a ____________ and not a ____________
(lower number)?
Summarize the entire MI session
Trained MI coaches with nutrition or psychology backgrounds conducted the

sessions (Madson, Landry, Molaison, Schumacher, & Yadrick, in press). In
Table3.5 we highlight the processes of MI using the MI feedback sessions. This
example was adapted from the HUB City Steps MI counselor manual but is not
a script (Madson, Bonnell, McMurtry, & Noble, unpublished manual).
T H E FO U R PR O C ES S ES O F M OT I VAT I O N A L
I N T ERV I E W I N G:A N A LC O H O L PR E V EN T I O N E X A M PL E
For more than 20years, the Brief Alcohol Screening and Intervention for College
Students (BASICS; Dimeff, Baer, Kivlahan, & Marlatt, 1999)has been used on
college campuses nationwide. The BASICS program is an alcohol prevention
program focused on high-risk students with slight yet detectable evidence of
alcohol abuse (e.g., evidence of heavy drinking episodesbinge drinking or
drinking-related consequences). With a solid grounding in MI, the BASICS
program involves a student meeting with a BASICS counselor for two sessions. Session one involves an assessment of alcohol use and related problems/
risk associated with use. The second session involves personalized feedback and
discussion about assessment results in a manner aimed at facilitating student
motivation to better protect them when drinking. Table3.6 provides an illustration of how the feedback session, as implemented at The University of Southern
Mississippi, follows the four processes of MI.
Table3.5. Health Promotion Example of the Four Processes

MI Process
Application to HUB City Steps
Engaging
Thank participant, engageobtain reaction to participation in HUB

Steps and set the stage for coaching session.
Thank you for participating in our health fair today. How was your
experience with the different activities you participated in today?
[Reflect client response]. My name is Mike Madson and Iam a health
counselor for this project. My job with HUB City Steps is to discuss
with you some of the information gathered today based on what you
think is important and to help you decide what, if anything, you may
want to change in relation to your health and how you may go about
changing. How does that sound to you?
[reflect]
Focusing
Agenda settingto focus discussion on health indicators important

to client by introducing Know Your Numbers card.
If it is okay with you, Id like to talk about the results of your assessment
today. This is what we call your Know Your Numbers card. This card will
be filled in each time you come back here. In looking at this card you will
see information about your results and information about where your
score falls in terms of health. For example, here is information about
your blood pressure and where your score falls within a healthy range.
We looked at different areas that would seem the most important for you
to discuss.
[Reflect client responses].
What is next most important for you?
Provide feedback about health results and evoke clients reasons,
need, and ability to change.
Using Elicit-Provide-Elicit, provide information on participant results
and MI-consistent strategies to help participant increase readiness to
change.
You indicated that you are most concerned about your blood
pressure. What sort of things do you know about blood pressure?
[Reflect client responses]. In looking at your blood pressure today
compared to healthy levels, it appears your blood pressure is a bit
high. What do you make out of that given what you know about high
blood pressure?
[Reflect client responses].
This process could be repeated for different concerns clients have
and could be summarized after.
MI Process
Evoking
Summarize and elicit.

You identified several factors on your Know Your Numbers card that
concerned you. These included high blood pressure, higher weight
than youd like, and not having as much energy as youd like.
[Use MI consistent strategies to elicit]
How important is it for you to make some changes to your health?
[reflect]
What are some of the reasons you might want to change your health?
[reflect]
What might your life look like 5years down the road if you changed/
didnt change your health?
[reflect]
What are some of the good things about your current behavior?
What are some of the not-so-good things?
Planning
Summarize client discussion about change.

If it is okay with you Iwould like to summarize what we discussed.
You expressed concern about your health, in particular your blood
pressure, weight, and limited energy. It is important to you to change
some of your eating and health to be a role model for your children.
You were a bit uncertain about modifying your diet because you dont
want to disappoint your family by not cooking their favorite foods,
and at the same time you recognize how it might be valuable to help
your family eat healthier. Also, it is important for you to have more
energy, and you indicated how eating healthier and increasing your
physical activity would be the best ways for you to become healthier.
Given all of this, what do you think you may want to do?
[reflect]
Present participant with menu of change options
If youd like we can talk about some changes you could make to
improve your health. To help us, we have the menu of options that other
individuals have used to become healthier. Here is a sheet that includes
some behaviors that can be important in helping people manage similar
concerns to yours. This area represents formal exercise like walking.
This area represents increasing physical activity in your daily life, like
taking the stairs rather than the elevator. This area represents eating
healthier, which may include eating more fruit and vegetables. You will
also notice some empty areas. These represent your ideas that are not
represented by the other areas. What, if any, areas here would you wish
to talk about, or perhaps there are other things you want to raise that
are more important to you in relation to changing?
(continued)
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Table 3.5.CONTINUED
MI Process

Elicit a plan from the participants aspects related to a specific plan.
What is it specifically that you may want to do?
[reflect]
What are your reasons for making this change?
[reflect]
What are your goals for making this change?
[reflect]
What might be the first step in your plan?
[reflect]
Who might help you reach your goals?
[reflect]
What sort of results do you expect from changing?
[reflect]
Summarize the plan emphasizing the fit for the participant (goals,
needs, intentions, and beliefs) and evoke commitment.
Let me see if Iam following you. You want to eat more fruits and
vegetables and you want to start walking each night after dinner
for at least 20 minutes. For you, these two changes are important to
help you manage your blood pressure, increase your energy, and to
be a healthy role model for your children. The first step is to look for
sales on fruits and vegetables and to get a pair of walking shoes. You
indicated that your neighbor will be interested in walking with you
and that you will ask her to set up a walking schedule. It is really your
hope that by making these changes you will lose some weight, become
less winded when walking, and feel better about yourself. Is this a plan
you can commit to?
By learning more about and focusing on the four phases of a motivational

interview, you can better appreciate how to guide clients in a discussion about
changing. Many providers we have trained are tempted to jump straight to
planning and focus an interaction immediately on identifying solutions to
clients problems. While this may sometimes be an effective strategy with clients who enter a helping relationship ready, willing, and able to change, it is not
likely to be effective for clients who do not come in with that level of motivation.
Understanding your clients, uncovering a shared focus for change, and evoking
Table3.6. Alcohol Prevention Example of the Four Processes

MI Process
Application to BASICS
Engaging
Engaging in the first BASICS Session

Hello, my name is Mike Madson and Im one of the BASICS
counselors. Welcome to the BASICS program. Thanks for coming
in today. Iunderstand that you were asked to attend the BASICS
program by your hall director. However, Iwould value the
opportunity to understand your perspective in relation to why you
are here. If you are willing, tell me a little about your perspective on
what happened and what you think about having to attend BASICS.
[reflect what the client has said]
If it is all right with you Iwould like to provide some information
about the program and what you can expect as well as answer any
questions for you. How does that sound? My job is to work with you to
gather and discuss some information in relation to your alcohol use.
The goal of BASICS is not to determine if you have an alcohol problem
or put some label on your drinking. Instead my goal is to talk with you
about the information you provide about your drinking, what that
information means to you, changes you have already made, and based
on what you think is important decide what, if anything, you may want
to change in relation to your drinking. How does that sound to you?
[reflect]
Engaging in the feedback BASICS session.
Welcome back. Thank you for coming in today. How have you been
since our last meeting?
[reflect]
Before we begin talking about the information you provided last time
we met, Iwonder if you had any questions or concerns about our last
meeting, or had any reactions to the meeting or the questionnaires
you completed.
[reflect]
If Imight provide some information, you may remember from
our last meeting that the purpose of this meeting is to discuss the
information you gave about your alcohol use. It is my hope that we
have a collaborative conversation, so please stop me along the way to
ask questions or clarify things. Does that sound okay to you?
[reflect]
(continued)
Table 3.6.CONTINUED
MI Process
Focusing
Agenda setting to focus the discussion.

We have a bunch of things to discuss; are there any things that you
are particularly interested in talking about?
[reflect]
One place we could begin, if you would like, is to review your
self-monitoring form. How does that sound?
[reflect]
Provide personal assessment feedback using elicit-provide-elicit.
From your perspective, in what ways, if any, has alcohol gotten
in your way or resulted in unpleasant experiences? Based on the
information you provided, it appears that you often do things when
drinking that you later regret. What do you make of that?
Evoking
People have many different reasons for drinking alcohol. What are
some of the reasons you drink alcohol? How might that influence how
much you drink or when you decide to stop drinking?
[reflect]
Sometimes students decide to engage in strategies when they drink to
reduce the negative consequences they experience. How might that fit
or not with your goals for dinking?
[reflect]
On a scale of 0 (not important) to 10 (very important), where would
you place the importance of learning about new or additional ways to
protect yourself from negative consequences when drinking? [Client
responds saying5]. What makes it a 5 and not a 3.
[reflect]
What may be some of the drawbacks to using safe drinking strategies;
what may be some of the benefits?
[reflect]
Planning
Summarize to transition to planning

We started today and you were unsure whether you wanted to make
any changes to your drinking. Part of you enjoys drinking the way
you are now and you receive enjoyment from partying with your
friends. At the same time you learned that your drinking has led to
an increase in negative consequences and you have felt increasingly
embarrassed by things you have done when drinking. You indicated
that you would like to learn some strategies that you can use to
reduce the consequences you have experienced when drinking. What,
if anything, would you like to do?
MI Process
[reflect]
If youd like we can talk about some strategies you might consider
using when you drink to reduce the risk of negative consequences.
What are some things that come to your mind when we talk about
safe drinking?
[reflect] Here is a list that includes some behaviors that students at
this university and other college students use to protect themselves
when drinking. Some students use strategies to control their
consumption of alcohol such as avoiding shots or chugging alcohol,
or alternating an alcoholic and non-alcoholic drink. Other students
use strategies to reduce serious harm associated with drinking such
as using a designated driver or knowing what is in their drink. Based
on the drinking goals you mentioned before, which of these strategies
or others, if any, might you use to protect yourself when drinking yet
meet your goals?
[reflect]
Elicit to develop a plan
For you, knowing what is in your drink and using a designated
driver would be strategies you could use when drinking.
What might be your reasons for using those strategies?
[reflect]
In using these strategies, what do you hope will happen?
[reflect]
Who can help you use these strategies?
[reflect]
How will you know these strategies are working?
[reflect]
Before we close today Iwould like to summarize your plan of action
to become a safer drinker. For you, reducing the harm associated with
drinking is important because you are seeing increasing problems
when you drink. You expressed a willingness to become more aware
of what you are drinking and making sure to use a designated driver
who has not been drinking. These steps will help you to better manage
your drinking and to make sure you are safe. Your hope is that these
strategies will help you drink more responsibly and keep yourself out
of trouble and from doing things you later regret. You identified your
sorority sisters as people who can help you with this plan and that you
will inform them of your plan and goals. Is this something you are
willing to commit to doing?
68
clients motivations for changing are useful for helping clients develop the motivation necessary to undertake difficult changes. Many providers we train are also
tempted to focus on providing suggestions and giving advice when developing
change plans with clients. This may result in a plan that the client cannot or will
not follow. Collaboratively developing a change plan in an MI-consistent fashion
increases the likelihood that a clients plan will be successful. Our discussion of
the processes is simply an overview and readers are encouraged to read Miller
and Rollnick (2013) for more detail on the four processes.
PART II
Motivational Interviewing for

Clinical Challenges
Less Ready to Change

Many of the strategies widely employed by helping professionals assume that clients enter the helping relationship ready to make changes. For example, immediately following an assessment of a clients smoking behavior, a smoking cessation
specialist might describe the various available options for smoking cessation and
ask the client to choose one. In this case, the specialist is operating under the
assumption that because a client has come to a smoking cessation clinic, he or
she is ready to quit smoking. The transtheoretical model (TTM; Prochaska &
DiClemente, 1983)and its accompanying stages of readiness to change provide
a valuable framework for understanding clients who are less ready to change. As
mentioned in c hapter2, the TTM and MI evolved almost simultaneously and
they can be used complementary to each other. Whereas MI provides a framework for understanding how provider-client interactions can influence readiness
to change, the TTM helps us to conceptualize our clients readiness to change
based on attitudes, behaviors, and intentions they display according to five
stages. The quick reference provides a description of the five stages.
Quick Reference
Stages of Readiness to Change
Precontemplation:Not aware a change is needed. Pros of not changing outweigh
pros of changing. Avoids talking about change.
Contemplation:More aware of need to change. Recognizes the negatives of not
changing. Concerned about behavior.
Preparation:Intending to change. Pros of changing outweigh pros of staying the
same. More engaged and making plans to change.
Action:Taking steps to change.
Maintenance:Preventing lapses and relapse after changing.
Typically, clients who are less ready to change tend to be at the precontemplation or contemplation stage of readiness to change. In other words, rather
than lacking motivation, individuals who are less ready to change are often not
aware of the need to change or are considering both the positives and negatives
72
M o ti vati o na l I nt e r v i e win g f o r C l inica l C h a l l e n g e s
of changing and not changing. Additionally, clients may be less ready to change
when they were not involved in the planning. Thus, they may be very ready to
change, but less ready to implement someone elses plan. When clients are less
ready to change they can show us in different ways, including not attending sessions, not adhering to treatment, or expressing no need to change (e.g., that they
are attending simply to satisfy a mandate or referral). Fortunately, MI is helpful for working with individuals who are less ready to change. We provide some
MI strategies for addressing challenges often associated with clients who are less
ready to change.
C L I N I CA L C H A L L EN G E 1:N O - S H OWS
Description
A challenge encountered in almost any setting where MI might be applied to
facilitate change is clients who frequently reschedule appointments (often with
little notice) and clients who fail to show for scheduled appointments. There can
be a number of factors that cause clients to miss scheduled appointments (with
or without notice to the provider), such as problems with childcare, forgetfulness, or unexpected events. Whatever the cause, missed appointments undoubtedly reduce a providers ability to help a client make positive changes. Missed
appointments can also create systemic problems that reduce the quality of service providers can offer. For example, just like airlines and hotels, many medical clinics find it necessary to overbook schedules to compensate for anticipated
canceled sessions and no-shows. Who hasnt been to the physician on a day when
everybody scheduled actually shows up? Wait times are often an hour or longer,
those waiting to be seen grow increasingly impatient and frustrated, and providers and office staff may feel a need to rush and thus may not offer the same
level of care or service they normally would. For these reasons, no-shows are an
important clinical challenge to address.
When clients are queried about the reasons for missed appointments, they
will provide a range of reasons. For example, Defife, Conklin, Smith, and Pool
(2010) found psychotherapy clients reported reasons for their missed appointments ranging from symptoms, to practical concerns, to motivational issues, to
negative treatment effects. To providers, these reasons may range from the seemingly reasonable (e.g., the school called to say my son had a fever and Ihad to
pick him up) to the seemingly absurd (e.g., my sons tarantula got out of its cage
and Ihad to find it before Icould leave the house). Many times, particularly
with clients who repeatedly miss or reschedule appointments, a provider may be
left wondering whether the reasons provided are truthful, or whether the missed
sessions are an indication that the client is not committed to his or her work with
the provider. Possibly wondering, Does this client also miss his appointments at
the barber? Does he forget to pick his daughter up from school? Does he blow off
social engagements? Or does he only do this to me?
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It is possible that provider mistrust and frustration with no-shows may be

exacerbated by a difficulty understanding the perspective of the no-shower.
Speaking from personal experience, we can probably collectively count on one
hand the number of times we have simply failed to show up for a scheduled
appointment or canceled at the last minute. In fact, research on characteristics
that have been associated with no-show suggests that individuals who serve as
providers in settings where MI might be employed may often differ in important ways from their clients who no-show. For example, a study of predictors
of no-shows at a community mental health center in Denmark revealed that in
addition to clinical- and employment-related characteristics, age below 25 and 9
or fewer years of education were predictors of no-showing (Fenger, Mortensen,
Poulsen, & Lau, 2011). Although not reported in the study, it is likely that most
providers at the center were above age 25 and had 10 or more years of education.
The following example illustrates a typical no-show scenario.
Example: Mary and her primary care physician have been discussing her
weight at annual check-ups for several years. Over that time, Mary has
progressed from overweight but generally healthy, to obese with metabolic
syndrome, to severely obese with type 2 diabetes. Mary reports that she has
repeatedly attempted to lose weight, but always loses only a few pounds and
quickly regains them. Marys physician believes that successful weight loss is
crucial to Marys health, and has referred her to a dietician for nutritional
counseling. Mary rescheduled her initial visit with the dietician two times,
resulting in a delay of almost 3months between the referral and her initial
visit. Since the initial visit, Mary has returned for follow-up only once in the
last 6months, even though she and the dietician agreed to meet monthly to
track her progress and make adjustments to her diet as necessary.
Proposed Strategy 1:MI-Consistent Referrals

Perhaps the most difficult no-show problem to address is the client who no-shows
the first appointment. Although there are a number of reasons that clients may
no-show, low motivation has been identified as one reason clients might no-show
for initial appointments (Peeters & Bayer, 1999). The good news is that incorporating MI into the referral process can increase initial session attendance (Seal
etal., 2012). There are multiple ways to make referrals that do not actually occur
within the context of a motivational interview more MI-consistent, such as asking permission (e.g., If its okay with you, Id like to refer you to a dietician to
provide additional support and guidance on your weight loss efforts), emphasizing control (e.g., Im going to go ahead and make a referral to a dietician, but
it is really up to you to decide whether that is going to be the right strategy for
you), or offering choices (e.g., I think we have three options right now:you can
continue to try to lose weight on your own using some of the ideas your friends
74
have shared with you, Ican go ahead and refer you to a dietician now so you can
start working with someone on changing your diet, or Ican follow up with you
in 3months and we can revisit the issue then). Each of these strategies introduces some element of collaboration and support of autonomy, but on their own,
do not make the referral fully MI-consistent.
As outlined in chapter3, a provider and client will proceed through a series
of processes during a motivational interview:engaging, focusing, evoking, and
planning. Although the progression may not always be neatly stepwise and
linear, each process builds upon the prior processes in important ways. For
example, it would be difficult to collaboratively identify a focus for an interaction with a client who is not engaged in the interaction. As referrals occur
during the planning process of a motivational interview, making a referral that
is fully MI-consistent relies upon first engaging the client, collaboratively identifying a focus for the interaction, evoking the clients own motivations for
making a change, and then collaboratively developing a plan for change that
may include a referral.
The MI-consistent referral will be of little use to the provider who is on the
receiving end of a referral that was made in an MI-inconsistent fashion and
results in a client who never makes contact with the provider. Thus, we present
this not as a strategy for addressing no-shows in which the client never shows up
for the initial visit, but for reducing the likelihood that the clients to whom you
offer referrals will end up as future no-shows.
Example:MI-Consistent/Inconsistent Referrals
The following examples will illustrate MI-consistent and MI-inconsistent
referrals to a dietician for Mary, the client introduced in the earlier example.
Client Statement:I keep trying to lose weight, but Inever lose more than a
few pounds and Ialways gain it right back.
MI-Inconsistent: You need to meet with our dietician. She can help you
plan a diet you can stick to. Ill have the nurse call in the referral after this
appointment.
This is an MI-inconsistent referral because it is not collaborative. The provider tells the client what to do and makes the referral without having any
understanding of whether the client is interested in working on weight loss,
why she is interested, or the ways in which she prefers to approach weight
loss.
Somewhat MI-Consistent:Many of my patients find meeting with a dietician very helpful when they get stuck. Does a referral to our dietician seem
like something that would be helpful for you?
This referral is somewhat MI-consistent because the provider acknowledges
that although a dietician has been helpful for others, it may not be helpful
for this particular client. The provider also invites the client to express disagreement with the providers views on the benefits of the referral. It is not
75
fully MI-consistent, however, because the provider offers advice without

first seeking to elicit the clients own ideas about weight loss.
MI-Consistent:
Engaging:That must be very frustrating [uses reflection to help engage the
client].
Client Response:It is.
Focusing:I do need to review a few changes in your blood sugar with you
before we wrap up, but what are your thoughts about first spending a few
minutes talking about the struggles youve had with your weight? [Asks an
open question that invites Mary to help focus the session].
Client Response: I think that would be very helpful. I know that it is so
important for my health and that maybe Icould even reverse my diabetes if
Ilost weight. Ireally am trying, Ijust cant seem to stick to a plan.
Evoking:Weight loss is hard work [offers a supportive statement to maintain
engagement]. In addition to the role it might play in helping you manage and
possibly even reverse your diabetes, Im wondering what other benefits you
hope you might obtain from losing weight? [Asks an open question to evoke
change talk].
Client Response:I know Id feel better about myself if Ilost some weight. Ive
never been skinny and Idont know that Id want to be, but Ive also never
been this heavy. Ithink my kids also worry about me now that Im so heavy
and that makes me feel really guilty.
Planning:It sounds like there are a lot of reasons youd like to lose weight.
What do you think is a good first step? [Use an open-ended question to allow
the client to collaborate on the planning]
Client Response:I know Ieat too much, especially when Im stressed out.
Sometimes Ill order a family meal just for myself.
Planning continued:It sounds like you believe making some changes to your
diet is an important first step. One option you may or may not be interested in
is for me to refer you to a dietician so she can help you plan a diet that would
be a good fit for you. What are your thoughts about that?
This response is MI-consistent, because the referral is made in a collaborative fashion and only after the provider has sufficient information about the
clients preferences and motivations to know that a referral to a dietician is a
good fit for the client. It is also MI-consistent because the provider gives the
client the opportunity to refuse the referral, which supports her autonomy.
Proposed Strategy 2:Giving Information

One of the most basic, but at times very important, strategies to address missed
appointments is provision of accurate and objective information. Although
76
giving information is not a strategy that is central to the practice of MI, when
done in an objective and engaging fashion, it is MI-consistent (Lane & Rollnick,
2009). Two pieces of information that may be especially important in deterring
missed appointments are: (1) the purpose of the appointment, especially as it
relates to the clients goals; and (2)the providers appointment policy (e.g., cancellation policy, penalties for missed appointments, etc.). Clients who do not
understand what will happen at the appointment or who are uncertain of the
benefit they are likely to receive from the appointment may be less likely to make
attending the appointment a priority. This might be particularly true for clients
who are referred by other providers, coerced by the legal system, or strongly
encouraged by friends or family members to seek the services of a particular
provider. Clients who are not made aware of the appointment policy may not
understand the implications of missed appointments or the appropriate steps to
take when they need to miss an appointment.
Example:MI-Consistent/Inconsistent Giving Information
strategies for giving information to clients who have missed appointments.
Provider Statement:I see its been 5months since our last appointment.
Client Statement:I couldnt make it to our last appointment, because my
foot was bothering me again, and then the next appointment Icould get was
a month later.
MI-Inconsistent:Yeah. Well, its a very full clinic, so you need to make coming in a priority. If you dont get your diet under control you run the risk of
losing your foot and Iknow you dont want that.
This statement gives the client some information about the appointment
policy and the purpose of the appointment, but the information is not presented in an objective fashion and thus is not MI-consistent. The provider
blames the client for the missed appointment (accusing her of not making it
a priority), and then confronts her about her dietary control (trying to scare
her into better attendance).
Somewhat MI-Consistent: That happens sometimes. This is a very a full
clinic.
This statement is somewhat MI-consistent. The provider offers information that is relevant to what the client has said and is objective. However,
the provider does not ask permission to offer information and thus misses
an opportunity to enhance collaboration and increase the clients sense
of autonomy. Perhaps more importantly, the provider does not empathically address the clients seeming sense of frustration with having to wait
a month for an appointment. Thus the providers response might seem dismissive to the client.
MI-Consistent:If its okay with you, Id like to take a moment to address that
concern with you. [Awaits affirmative response from client]. This is a pretty
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full clinic, so often the next available appointment is a few weeks or even a
month after clients call. That can be a challenge because monthly appointments are considered very important for our clients who are diagnosed with
type 2 diabetes:dietary management of blood sugar helps reduce risk for diabetic complications like foot problems. What are your thoughts about this?
This response is MI-consistent, because the provider offers the information
in an objective fashion. The provider does not seek to chastise or blame the
client for missing the session or scare her into coming regularly by presenting a worst-case scenario. Instead, the provider presents information
that will help the client decide what level of priority she wishes to assign
regular attendance of appointments. Moreover, the provider tries to express
empathy with the clients underlying feelings about having difficulty getting an appointment by using words like concern and challenge. Finally,
the provider elicits the clients reactions to the information to enhance
collaboration.
Proposed Strategy 3:Planning

Planning is another MI-consistent strategy that can be used to address missed
appointments, particularly if they occur with regularity. As outlined here and in
chapter3, planning is a collaborative conversation between a provider and a client about how a client will achieve his or her goals. Planning only occurs after a
client has been engaged, a focus has been identified, and a clients desire, ability,
reasons, and need for change have been evoked. For clients who have expressed
a commitment to attending appointments but seem to have difficulty following through on this commitment, planning that focuses specifically on appointment attendance may help them overcome practical or motivational barriers to
follow-through.
Example:MI-Consistent/Inconsistent Planning
strategies for planning with clients who have missed appointments.
Client Statement: I couldnt make it to our last appointment because my
a month later.
MI-Inconsistent:I think we need a plan to help you attend visits more regularly. Do you have a calendar or schedule where you could write down your
appointments? If not, maybe you could post your appointment card on your
bathroom mirror or refrigerator. You know, somewhere where youll see it?
Im also wondering if the reminder calls are coming to the best phone number.
Maybe you should pick a better number to make sure you dont miss the calls?
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This provider response is MI-inconsistent because it is not a collaborative approach to planning. Instead of seeking the clients input about why
attendance is difficult and what the best approach to improving attendance
might be, the provider assumes the expert role and begins offering the client advice about how best to attend future appointments. This approach is
likely to elicit sustain talk and discord as the client is placed in a position
to defend not making her appointments or why a strategy might not work.
Somewhat MI-Consistent:Do you want to work together to develop some
strategies to help prevent that from happening to you again?
This statement is somewhat MI-consistent. The provider invites the client
to develop a plan to reduce no-shows in a collaborative fashion. However,
the provider uses a closed question, and thus invites only a brief response.
Additionally, the provider jumps to planning before reflecting or eliciting
anything from the client about her desire, ability, reasons, or need to attend
more follow-up visits.
MI-Consistent:It seems like it has been difficult for you to make it in for
appointments. Iwonder if before we talk about your diet, we could talk about
that. [Waits for affirmative response from client]. Given that you always
reschedule, Iget the sense that youd like to make it to more follow-ups. If its
okay with you, maybe we can work together to figure out how we can make
that happen.
This response is MI-consistent because the provider uses reflective listening
and asks permission to introduce the change plan. It is also MI-consistent
because the provider engages the client in a collaborative process of developing the change plan that begins with a reflection of the clients apparent
desire to change.
Although not required, planning will often be accompanied by preparation of a written change plan (Miller and Rollnick, 2002). The sample
form presented in Table 4.1 illustrates how a provider might develop a
written change plan that specifically addresses missed appointments.
Although many providers prefer not to use written change plans, feedback we have received from many clients over the years is that written
change plans serve as a valuable reminder of key concepts discussed with
a provider.
Proposed Strategy 4:Emphasizing Autonomy

As noted in chapter2, respecting client autonomy is part of the foundational spirit
of MI. Missed appointments are an important reminder to providers that client
autonomy is also a practical fact of our work as helping professionals. Providers
can make referrals, schedule appointments, and even make reminder calls, but
ultimately the client will decide whether he or she shows up at a recommended
or required visit. Explicitly emphasizing client autonomy is an MI-consistent
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Table4.1.Sample Change Plan for Missed Appointments

These are the reasons Iwant to attend follow-up appointments:
Regular follow-up visits keep me accountable for my diet.
Iwill be more likely to lose weight if Icome to follow-up visits.
My goal for follow-up appointment attendanceis:
To attend all follow-up visits on the recommended schedule.
Things that have made it hard for me to attend follow-up visitsare:
Ifeel embarrassed to tell you about things Ihave been eating.
Ihave trouble motivating myself to leave the house and come to the
appointments.
The actions Iwill take to overcome these barriers to attending follow-up visits:
Iwill remind myself that even if Idont follow my diet, going to appointments
is important and something Ishould feel proud aboutat least Im doing
something.
Iwill schedule appointments on days when Ihave other errands, so Ihave to
leave the house anyway.
Iwill make a list of all the reasons it is important for me to come to these
appointments and post it on my bathroom mirror.
You and others could help me attend more follow-up visits in theseways:
You could remind me that it is okay for me to come in even if Ihavent been successful on my diet.
My sister could help keep me accountable if Itell her Ihave been having trouble
going and ask her to remind me.
If the plan is not working:
Iwill remind myself that you are not mad at me, and want to work with me to
try to attend appointments.
Iwill make another list of why this is so important to me and keep trying.
strategy that may help reduce missed appointments, particularly for clients who
feel some level of external coercion to attend appointments.
Example:MI-Consistent/Inconsistent Emphasizing Autonomy
The following examples will illustrate MI-consistent and MI-inconsistent strategies for emphasizing autonomy with clients who have missed appointments.
Client Statement: I couldnt make it to our last appointment because my
a month later.
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MI-Inconsistent:You need to decide whether this is something you want to

commit to or not!
This provider response is MI-inconsistent because the provider is giving
the client a direct order. Also, the tone of voice we intended to imply by
the exclamation point demonstrates a lack of empathy and unconditional
positive regard, instead conveying the providers irritation with the client.
Somewhat MI-Consistent You are the one who has the power to decide whether
these monthly appointments are something you want to commit to or not.
This provider response is somewhat MI-consistent. The provider emphasizes that the client has control over whether she continues working with
the provider or not, which is MI-consistent. However, the provider uses the
word want, which subtly conveys that she believes the clients motivation,
not foot problems or scheduling difficulties, is the root of the patients lack
of attendance. Thus the client may feel blamed or confronted by this utterance rather than empowered. The provider also fails to express empathy for
the clients frustration or foot pain. This could lead the client to believe that
the provider does not really care about her as a person, only whether or not
she shows up for appointments.
MI-Consistent: I know it sometimes takes a major effort to make it here
for appointments, and ultimately it is up to you to decide whether monthly
appointments are something you can commit to now.
This response is MI-consistent because the provider first supports the difficulty the client sometimes has making it to appointments, and then without
sarcasm or judgment reminds the client that ultimately it is up to her to
decide whether she would like to attend regular appointments or not. Using
this MI-consistent strategy does not guarantee that the client will commit
to coming to regular appointmentsshe might decide that she does not
want to meet with the dietician monthly at this time. Although probably
not the ideal outcome from the perspective of the dietician, this is not a bad
outcome. If Mary is truly not ready to commit to monthly appointments
with the dietician, it is better that she and the dietician can talk about this
openly. This leaves the door open for Mary to return to the dietician when
she is ready.
C L I N I CA L C H A L L EN G E 2:N O N -A D H ER EN C E
Description
Many providers are attracted to MI as a way to help them better work with the
issue of non-adherence. Consistent with the MI literature, we are choosing to use
the term adherence versus compliance (Zweben & Zuckoff, 2002). You may
remember from chapter1 that MI has research support for facilitating treatment
engagement and adherence (Lundhal etal., 2010). Adherence generally refers to
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the extent to which a client follows a providers instructions or advice (Levensky

& ODonohue, 2006). Non-adherence is an issue often faced by providers, especially when clients are required to change in some way. Many medical treatments,
including taking medications or surgery, require some form of behavior change,
such as following the prescription or increased physical activity. People we train
frequently express frustration with their clients non-adherence to a treatment
program because adherence is linked to positive treatment outcomes (Bisono,
Manuel, & Forcehimes, 2006). With further exploration, it is often revealed that
this frustration is associated with conceptualizations that non-adhering clients
arent motivated, are in denial, dont have enough knowledge or skill, or simply
do not care about their health or situation. Clearly, when we conceptualize clients non-adherence in this way, it can increase our frustration and also influence
the way we respond. Many times this conceptualization of client non-adherence
triggers the righting reflex (see c hapter2) and leads us to educate, warn, lecture, or even berate clients in an attempt to convince them of the need to adhere
to our recommendations. However, those responses tend to be inconsistent with
an MI approach to working with non-adherence.
Client non-adherence is expressed in several ways, and from an MI perspective it is an indicator that the provider and client are not on the same page. In fact,
Levensky and ODonohue (2006) indicated that factors such as client-provider
communication, trust, and mutual conceptualization of the problem contribute to non-adherence. Some clients are considered non-adherent because they
come to appointments late or simply do not attend appointments (see section
on missed appointments in this chapter for further information). This form of
non-adherence is common when clients come to treatment at the suggestion of
someone else and not by their own choice. Thus, non-adherence may be due to
the clients feeling as though they have no input into the treatment.
Example:Shelia is a 20-year-old college student who was told to see a peer
health educator by the student health services to learn to implement safer
sexual practices. Immediately upon entering the room with the peer health
educator, Shelia indicates that the health services worker was overreacting
and that she is a normal college student and behaves the same sexually as all
of her friends. Nonetheless, she agrees to attend sessions. Since that initial
meeting, Shelia sporadically attends sessions and sometimes goes weeks without attending. She often arrives 10 minutes late for meetings and always has
a reason for missing meetings or arriving late. When asked directly, Shelia
states she is committed to attending the meetings because she was told to do
so, but her behavior is inconsistent with this assertion.
Sometimes clients do not even engage in a recommended treatment or drop
out early. This form of non-adherence may be seen in allied health and behavioral
health services, where clients are referred by medical providers for treatments
in addition to medical interventions. However, clients may be less confident in
the need for non-medical treatments or question the motives of the referral to
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additional treatments. As psychologists who have worked in medical settings,

we often encountered clients who felt dismissed or invalidated because they had
been referred to us to address medically related issuesthe doctor thinks its all
in my head. This client mindset may keep clients from engaging in treatment.
Additionally, there may be financial, logistical, or other barriers that may influence clients abilities to attend sessions.
Example:Karl is a veteran who was referred to a psychologist by his physician assistant to help address his chronic sleep difficulties. Before the interview begins, Karl indicates that he doesnt believe seeing a shrink will help
his sleep and that he just needs some sleep medication. However, it becomes
apparent that Karls sleep difficulties are associated with trauma that he
experienced in the military. When this feedback is shared with him and a
course of treatment is suggested, he denies any problem with his military service. Karl never returns to treatment.
Finally, clients may attend all of their scheduled sessions and be on time, but
do not carry out the plans discussed for out-of-session activities, such as homework or taking medications. This form of non-adherence can be baffling for
many providers who assume that when clients readily walk in the door that
they are ready to do what is necessary to change. However, this is not often the
case when it comes to behavior change, and to be MI-consistent providers need
to recognize the role of ambivalence.
Example: Jody is a 47-year-old woman who entered psychotherapy for her
social anxiety. She is also seeing a psychiatrist for medication management.
She has expressed the goal of wanting to reduce her anxiety and to be able
to attend more social events without worry. Jody reports that she does not
take her medication regularly as she worries about developing an addiction, though her medication is not addicting. She indicates that she wants to
do what it takes to become less anxious and more social; thus she agrees to
treatment involving exposure and skill building. However, she has a pattern
in treatment of not completing her self-monitoring, exposures, or skill practice outside of session (for more information about specifically addressing
non-adherence related to anxiety, see also chapter6).
Regardless of how non-adherence is displayed, from an MI perspective it is an
indication that the provider and client are not on the same page in relation to the
change or how to go about changing (Bisono etal., 2006).
Proposed Strategy 1:Evocative Questions

Using evocative questions in relation to non-adherence can help avoid the righting reflex. Evocative questions can also help the provider adopt an approach that
is grounded in genuinely trying to understand what concerns the client may have
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about changing or not, what their personal motivations for changing may be
versus what a referral source may want, and what potential solutions seem reasonable. Remember the U from RULE in c hapter2understanding the clients
motivations. It is the clients own motivations that are more likely to predict their
engagement in and adherence to treatment. Thus it is very important to elicit
these from clients, especially when trying to engage them into treatment.
evoking for clients with non-adherence issues.
Client Statement:I think all Ineed is medicine for this problem. No offense but
Idont come here as often because Idont think talking about my sleep will help.
MI-Inconsistent:Do you really think that medication is the only thing that
will help you sleep?
This question is MI-inconsistent for two reasons. This question is a closed
question and unlikely to foster open discussion about the topic from the client. Additionally, the do you really part of the question is likely to engender discord as it can be perceived as judgmental and confrontational.
Somewhat MI-Inconsistent:Why dont you think therapy will be helpful?
This question is somewhat MI-consistent. It is an open question and thus
invites the client to share. However, the Why dont you... phrasing of the
question subtly implies that the client should think therapy will be helpful
and thus may elicit discord as the client feels a need to defend his position
to the provider. The phrasing of the question is also likely to evoke sustain
talk (reasons not to get this particular treatment) rather than evoking the
clients perspectives on what would be helpful.
MI-Consistent:You want to solve this sleep problem, and for you medication
seems like the best option. If it is okay with you Id like to hear your thoughts
about why you think your physician referred you to me.
This statement is MI-consistent for a few reasons. First, with the reflection,
the provider communicates listening to the client and an understanding
of the experience. Rather than jumping into education, the provider asks
an evocative question that invites the client to comment on his/her understanding as to why the physician made the referral. This approach helps the
provider avoid the righting reflex (e.g., behavior change can help with sleep
too) and fosters client engagement in the discussion.
Proposed Strategy 2:Scaling Questions

A strategy related to the use of evocative questions is to ask scaling questions,
sometimes called importance and confidence rulers. In MI, these types of questions help the provider gauge whether clients reluctance to change may be due to
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their perceived importance of the change or their perceived confidence in their

abilities to change (Miller & Rollnick, 2013). For instance, the provider can ask
On a scale of 0 (not at all important) to 10 (extremely important), how important
is it to you to make this change? The use of scaling questions is not unique, but
what is unique is the intentional follow-up to scaling/ruler questions. In MI, following up to ask what makes the number on the scale higher versus lower is
intended to elicit reasons why change may be important or why clients may have
some confidence in their ability to change.
Example:MI-Consistent/Inconsistent Scaling Questions
scaling questions for clients with non-adherence issues.
Client Statement:I think all Ineed is medicine for this problem. No offense
but Idont come here as often because Idont think talking about my sleep
will help.
MI-Inconsistent:On a scale from 0 (not at all important) to 10 (very important) how important is it for you to attend these sessions?
This is definitely a scaling question but is MI-inconsistent for two reasons.
First, the use of a question like this, especially in the context of missed
appointments, could lead the client to become defensive and increase discord. Second, the scaling question is not really about change (i.e., improving sleep, reducing trauma symptoms); it is more about the importance of
the sessions. Thus, there is a missed opportunity to explore the clients hesitancy to change or importance of change.
Somewhat MI-Consistent:On a scale from 0 (not at all) to 10 (very much),
how important do you think this treatment is relative to the medication?
This scaling question is somewhat MI-consistent. The provider uses a scaling question to better understand how the client feels about psychotherapy.
The use of the question also likely conveys to the client that his concerns
about treatment are being taken seriously by the provider. However, the
phrasing of this question is such that the discussion that follows the question is unlikely to help the client move toward the improvements he desires
in sleep. Thus the utterance is empathic and collaborative, but may miss an
opportunity to guide the client toward positive change.
MI-Consistent:You have a lot going on in your life and found the time to
make it here today to address your concerns. If Imight ask, on a scale from
0 (not at all important) to 10 (the most important thing for you), where does
making changes to your sleep fall?
Client response:About a 4.
MI-Consistent:So it is mid-range on the sale. What makes the importance
a 4 and not a 2?
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These provider utterances are MI-consistent for several reasons. First, the
provider begins with an affirmation by reframing the client showing up as
a positive given all of the things going on in her/his life. Next, the provider
focuses on the change versus the non-adherence behaviors. By using a scaling question to focus on the importance of the behavior, the provider gets
a better picture where the change fits in relation to other things in the clients life. Finally, the follow-up question is likely to guide the client to discuss why there is some importance to changing the behavior, which is more
likely to build motivation.
Proposed Strategy 3:Looking Forward

Sometimes clients are less aware of how their non-adherence to treatment might
have an effect on their future. As humans we tend to have narrow perspectives
about our future as it relates to changing or not (Wagner & Ingersol, 2013). For
instance, in a medical setting a client may feel fine but be pre-hypertensive.
Because the client feels fine he may not see the need to address his diet or
exercise to lower his blood pressure. However, unless addressed, his blood
pressure is likely to get worse. Thus, one MI-consistent strategy that can facilitate adherence is helping the client connect how their current situation and
non-adherence might affect their life in the future. In MI, this strategy is called
looking forward.
Example:MI-Consistent/Inconsistent Looking Forward
looking forward for clients with non-adherence issues.
will help.
MI-Inconsistent: Yes, medication can help. However, if we look down the
road and you dont change thoughts and behaviors related to your sleep, your
sleep is likely to get worse, which will then increase your vulnerability to many
other problems!
The provider offers accurate information about the progression of sleep difficulties and the vulnerability for other issues if the sleep doesnt change.
However, the statement is MI-inconsistent as the provider is assuming
the expert role and providing the information without asking permission.
Additionally, rather than eliciting from the client about the future, the
provider simply connects the dots for the client. This approach fosters less
engagement and likely to elicit sustain talk from the client.
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Somewhat MI-Consistent:I have a different perspective. Would it be okay if

Ishared it with you? [Waits for affirmative response]. Ihave been doing this
for years, and generally people who rely on medication and dont address the
other problems contributing to sleep difficulties continue to have problems
with sleep.
This response is somewhat MI-consistent. The provider asks permission
before offering his professional opinion. However, the provider uses this
information to try to instill motivation for treatment rather than eliciting
the clients own concerns about what might happen if he does not pursue
any treatment other than medication for his sleep difficulties.
MI-Consistent: You wonder why all of these changes are necessary when
medication should help you with your sleep. Iwonder if we can look 5years
down the road for a minute. Lets say you decided not to make any of these
changes in relation to your sleep. What might your health look like? [client
responds] How might your health be different if you decided to make some
changes in your sleep behaviors?
This provider statement has several aspects that make it MI-consistent. The
provider reflects the clients concerns about changing. The provider asks
permission to look into the future and follows with two eliciting questions.
This approach is more engaging and collaborative. The provider makes no
assumption that the client will change and avoids the expert trap.
Proposed Strategy 4:Revising the Change Plan and Discussing

Options
Often individuals are less willing to adhere to treatment when they perceive that
they have few options in relation to the change; thus, they assert their independence by not adhering to the treatment plan. Aconcept from social psychology
will help to explain this. According to Brehm and Brehm (1981), individuals have
a natural tendency to react (or assert their independence) when they feel their
freedom is being taken away. In other words, as humans, it is natural for us to
argue against being told what to do. The ultimate way clients demonstrate this
is by not adhering to the change plan. In training providers to become more
MI-consistent when developing change plans, we often find that providers are far
less MI-consistent in this process than they believe themselves to be. Many providers prescribe a change plan followed by a question, such as, Does this sound
okay to you? Some providers mistakenly assume that this question makes the
entire planning process MI-consistent. This strategy seems to be based on the
belief that once a client indicates readiness to change it is the providers job (as an
expert) to tell him how. One way to avoid a client pushing back or not adhering to
treatment is to engage the client in the planning process. For example, a provider
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may discuss various change options and elicit which, if any, may seem to be most
appealing to the client. Given that MI-consistent planning was discussed earlier
in this chapter (see missed appointments section), this discussion will focus on
discussing options as part of the planning process.
Example:MI-Consistent/Inconsistent Discussing Options
discussion of options for clients with non-adherence issues.
will help.
MI-Inconsistent:For many people, medication can help but only so far. The
combination of medication and cognitive behavioral therapy is generally
most effective for people with your symptoms!
While accurate, the statement is MI-inconsistent. The statement appears to
adopt an expert role commenting on the effectiveness of medication and
cognitive behavioral interventions for sleep. Similarly, the provider offers
information in a fashion that is not fully MI-consistent because he/she did
not ask permission or announce that he/she was going to provide information. The statement is challenging to the client, prematurely focuses on a
problem, and prescribes a solution. All of these aspects of the statement are
likely to elicit sustain talk from the client and engender discord between the
client and provider.
Somewhat MI-Consistent:I think we have several options here. You could
continue to see me regularly and see how it goes. You could try some, but not
all, of the strategies Irecommend. Or you could discontinue this treatment and
come back again later, if you change your mind. What sounds best to you?
This response is somewhat MI-consistent. The provider gives the client
options and invites the client to choose which seems best. However, the provider does not ask permission before offering the options and does not leave
open the possibility that the client may have different ideas about what the
best solution might be. Thus although the provider seeks to be somewhat
collaborative in discussing options and updating the change plan, the effort
is lukewarm.
MI-Consistent:For you medication seems like a viable option, and youre
not too sure whether also working with me to address sleep behaviors is going
to give you additional benefit. At the same time, your psychiatrist has asked
for you to see me which suggests she thinks working with me might be beneficial. If it is all right with you, Id like for us to discuss some other options
that Ihave seen clients in similar situations use to help with their sleep. Ialso
recognize, that these options may or may not fit for you, and you may have
some additional ideas.
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This provider statement has several aspects that make it MI-consistent.

Beginning the statement with a reflection communicates that the provider
is listening and empathizing with what the client is saying. The provider
asks permission to engage in a discussion about options for change. The
provider discusses options in the context of what others in a similar situation have done to help with their sleep versus prescribing options based on
professional opinion or research. Finally, and discussed later, the provider
emphasizes the clients personal control to choose what she/he deems best.
Proposed Strategy 5:Emphasizing Personal Control

Related to the importance of discussing options in relation to non-adherence is
the need to emphasize clients personal control to choose what they think is best
for them. Miller and Rollnick (2013) highlight the fact that we really cant make
clients do something they dont want to do, and clients show us by not adhering
to their treatment plans. This idea also relates to reactance theory. One way to
address this issue is to remind clients that ultimately the choice for change is
theirs and no one elses. This is true even when they are mandated to change.
Example:MI-Consistent/Inconsistent Emphasizing Personal Control
emphasizing of personal control for clients with non-adherence issues.
Client Statement:I think all Ineed is medicine for this problem. No offense,
will help.
MI-Inconsistent:It is your choice what you do here, but Idont think your
psychiatrist is going to be very happy with you if you dont follow his advice
about adding psychological treatment.
The provider does emphasize the clients personal control; however, the
statement also includes an implied warning that the provider has to report
the non-compliance with treatment back to the psychiatrist, which may
lead to negative consequences for the client. In essence, by adding the warning the provider is communicating that the client does not have any control
in this situation. This statement may also enhance the clients sustain talk
or attempt to convince the provider that a problem doesnt exist. It also
could engender discord between the client and provider as the client may
feel threatened and that the provider is siding with the psychiatrist.
Somewhat MI-Consistent:Well its really up to you. No one can make you
come to these appointments if you dont want to.
This statement is somewhat MI-consistent. The provider emphasizes the clients personal control, which is MI-consistent. However, the provider does
so without expressing empathy or encouraging the client to further explore
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whether treatment termination is the best option for him, all things considered. This might leave the client with a sense that the provider really does
not care whether the clients sleep improves or not, and is only interested
in making sure that the treatment slot is filled with someone who comes
regularly.
MI-Consistent: You are only here because your psychiatrist referred you
here, but psychological treatments for sleep dont make a lot of sense to you.
Definitely any changes you decide to make or not make, including seeing me
for treatment, are up to you and Icant force you to do anything. At the same
time Iwonder about your thoughts as to why your psychiatrist thought that
this might be beneficial for you.
This is an MI-consistent response for several reasons. The provider avoids
taking sides by empathizing with the clients frustration about being
referred by the psychiatrist. Next, the provider emphasizes the clients personal control to choose to make or not make any changes. Finally, the provider invites the client to comment on what his/her ideas about why the
psychiatrist may have referred him for additional treatment. Astatement
like this encompasses the spirit of MI, communicates acceptance and collaboration, and uses evocation. This statement is more likely to engage the
client, reduce sustain talk and discord, and help the client to be more open
to later suggestions.
C L I N I CA L C H A L L EN G E 3:C L I EN T I N VO LV ED I N
T H E L EG A L SYST EM
Description
Client involvement with the legal system can lead to particularly difficult
client-provider interactions. Legal involvement comes in many different
forms, each of which can introduce unique clinical challenges. Clients who are
court-ordered, court-referred, or encouraged to seek services by an attorney
prior to their court date to make a favorable impression upon the judge may
enter treatment pre-contemplative about behavior change (Thombs & Osborn,
2013). That is, these clients may not perceive any reason to make changes, and
may believe that the only benefit they will get from meeting with a provider is to
improve their legal standing. Clients of this type are most often found in the probation/parole system, substance abuse treatment, domestic violence treatment,
and similar settings.
Example:After a substantiated allegation of child abuse, Jane was sentenced
to probation and referred to an intensive parent training and anger management program. Custody of Janes children has been temporarily granted to
her ex-husbands parents and she has been informed that her children will
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not be returned to her custody unless she successfully completes the 12-week
program and satisfies other conditions of her probation. Jane has also been
informed that she may face additional legal penalties if she does not complete the 12-week program. Jane believes that stern physical discipline is an
essential part of raising responsible, well-behaved children and resents her
touchy-feely, liberal neighbor, who she is certain called in a report to the
child welfare department. During her intake interview for the program, Jane
is very quiet and reserved, and seems focused primarily on finding out what
the program will report back to the court and probation department and
what exactly the program requires to make a favorable report about her.
Interactions with legally involved clients who present for treatment or services
that are not required or encouraged by the legal system may still present serious
clinical challenges. Clients who are involved in pending litigation or who perceive that future legal involvement is possible or likely (whether or not this is in
fact true), may feel compelled to present themselves in a particular light in order
to achieve legal goals, such as a favorable legal settlement, or avoid anticipated
negative consequences of honest disclosure, such as a harsher sentence or loss of
custody of achild.
Example: Bob is in the midst of what could best be described as a messy
divorce and is seeking counseling to help him cope with the stress and address
symptoms of anxiety and depression that have emerged since he and his wife
separated. Bob would also like to use therapy as an opportunity to work on his
difficulty controlling his temper, as he believes that has contributed to problems in his marriage. Bob is reluctant to disclose this problem to the therapist,
however, because he is concerned that his therapy record will be subpoenaed
during the divorce proceedings. Bob is afraid that admitting he has an anger
problem may negatively impact him in the divorce proceedings.

One factor that can needlessly increase discord and decrease client candor during MI sessions with clients who are involved in the legal system is uncertainty
on the part of the client about whether and what types of allegiances or obligations the provider may have to the legal system. It is important to note that even
clients who have no involvement with the legal system may have such concerns.
For example, an individual who is being treated in the emergency room subsequent to a motor vehicle accident may be defensive or anxious when asked about
her use of drugs or alcohol prior to the accident, if she believes that information
will be or could be reported to police. Thus a very simple, MI-consistent strategy
we have found very useful in addressing this challenge is giving information.
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At the outset of an interaction with clients who have legal involvement of any
sort (or who may perceive legal involvement), it is important to provide clear,
unambiguous information about the providers role, if any, in the legal system.
As described further in c hapter3, to be MI-consistent, it is also important that
any information given to the client is delivered in an objective manner. Although
not technically required (Moyers, Martin, Manuel, & Ernst, 2010), it is more
MI-consistent and generally beneficial if providers ask permission before giving information. In the case of probation, parole, or similar contexts, providers should fully disclose the dual roles they have with clients. In one role the
provider represents the criminal justice system, reporting the clients progress
on meeting the conditions of his or her probation or parole, including violations. In the other role, the provider acts as an advocate for the client and tries to
help him or her achieve important goals (Walters, Clark, Gingerich, & Meltzer,
2007). As Walters and colleagues suggest, this dual relationship may decrease
the willingness of some clients to disclose certain information for fear of sanctions. However, the willingness of the provider to proactively provide full information about the dual relationship is highly consistent with the foundational
spirit of MI, which emphasizes collaboration and support of client autonomy
(see c hapter2). Moreover, in our experience, provision of such information may
reduce client willingness to disclose select details about their past or current
behavior, but it is likely to enhance client disclosures overall by fostering the clients ability to trust the provider.
In the case of a provider outside the legal system, who is simply providing a
service that may be of interest to the legal system (i.e., a community-based alcohol treatment provider working with an individual convicted of driving under
the influence of alcohol or another substance [DUI] who was diverted to treatment), the client should be made aware that the provider is not part of the legal
system. The provider should also make the client aware of whether the legal system is likely to require a release of information and what types of information
(e.g., attendance, completion, progress, diagnoses, etc.) in order to consider the
clients treatment involvement in determining the clients legal disposition. The
ethical imperative for disclosure of a lack of relationship between the provider
and the legal system is not always as clear cut as the imperative for disclosure
of the presence of such relationships. However, provision of information about
the absence of a connection between the provider and the legal system may help
reduce discord or increase client candor in situations where the client might
believe such a relationship exists.
strategies for giving information to clients who have legal involvement.
Client Statement:I havent smoked marijuana in over a month. Idont know
how the drug screen came out positive.
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MI-Inconsistent:Marijuana use is a clear probation violation. You need to

take this treatment seriously and stop lying to us about your marijuana use.
Iam going to report this to your probation officer and Ihope he revokes you!
This statement gives the client information about the relationship between
the provider and the legal system, but it is MI-inconsistent because it does
so in a non-objective fashion. With this response, the provider obviously
discloses this information to the client to establish his own power over the
client (non-collaborative) and confront the client about what the provider
believes is a lack of candor.
Somewhat MI-Consistent:Before we continue, Ifeel Imust remind you that
Iam required to report this to your probation officer.
This statement is somewhat MI-consistent. The provider offers the information in an objective fashion. The phrasing I feel Imust expresses that the
provider values the clients right to have full information about the probation process. Thus, in a subtle way, this phrasing supports the clients
autonomy. However, the provider does not express empathy for the clients
current situation or support the clients autonomy in an overt way.
MI-Consistent: I imagine this unexpected result is upsetting and I would
like to discuss how this might have happened. Before we discuss that, Iwould
like to review what this means and doesnt mean in terms of your legal status.
Would that be okay? [Waits for affirmative response]. In addition to providing reports on your treatment attendance, your probation officer also requires
that we provide reports on your progress in treatment, including outcome of
urine drug screens.
This response is MI-consistent because the provider offers the information
in an objective fashion. The provider also asks permission to give the information, which supports client autonomy and enhances a sense of collaboration. The provider also reflects the clients inferred emotional reaction to a
positive drug screen, which demonstrates empathy.
Proposed Strategy 2:Emphasizing Autonomy

As noted in chapter2, a key element of the acceptance component of the foundational spirit of MI is respecting client autonomy. Regardless of what a provider
wants or hopes a client will do, the client is ultimately the one who determines
what he or she actually will do. Clients who believe change is possible and have
a sense of agency are more likely to be successful in making positive changes in
their lives (Bandura, 2004). Many clients who are involved with the legal system
actually have lost control over one or more aspects of their lives. Nonetheless, it
is very important for providers to recognize and respect that even clients who
are incarcerated and have lost their physical freedom retain autonomy over other
aspects of their lives (Farbing & Johnson, 2008). No matter what a clients legal
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status, he or she generally retains the autonomy to share or not share his/her
thoughts and feelings with a provider, to discount or take seriously a providers
ideas or suggestions.
Nonetheless, loss of autonomy or concern about loss of autonomy can make
it difficult for clients to actively engage in the change process. Clients may view
themselves as completely powerless and assume a passive role in encounters with
providers. Although this might make clients easier to manage and thus be viewed
as desirable in certain settings, it may ultimately undermine efforts to promote
positive changes in the clients lives (Bandura, 2004). Clients who do not collaboratively participate in the change process may have insufficient motivation
to carry out change, or may seek to make changes that are not a good fit for their
unique experiences, strengths, and preferences. For example, a client who is a
passive participant in discussions of employment may be assigned to employment that is of little interest to the client and does not make maximum use of
his or her unique skills and experience. Loss of autonomy or concern about loss
of autonomy in one area of a clients life may also give rise to unsuccessful and
counterproductive efforts by the client to assert their autonomy in other areas of
their life (Ryan & Deci, 2000). For example, a client who feels powerless because
of his or her involvement with the legal system may react negatively to other
aspects of life that are less defined or constrained.
Thus, it may be very important for providers who wish to help clients
with legal involvement make positive changes in their lives to be aware of
the impact of a clients loss of autonomy and make attempts to restore a clients sense of autonomy. Although emphasizing a clients personal autonomy
is an MI-consistent strategy that may be applied during any MI encounter, it
is perhaps most powerful with clients who have legal involvement. Using the
MI-consistent strategy of emphasizing autonomy involves (as you might guess)
supporting a clients autonomy by emphasizing those aspects of a clients life
that are within a clients control and actively working to help the client exercise
that control.
Example:MI-Consistent/Inconsistent Emphasizing Autonomy
strategies for emphasizing autonomy for clients who have legal involvement.
Client Statement:I miss one check-in and you are talking about revoking my
probation and sending me back to prison?
MI-Inconsistent: You made a bad choice, and now youre going to have
consequences.
Although this statement seems superficially like a support of the clients
autonomy because it mentions choice, it is MI-inconsistent. The provider
labels the clients choice as bad and actually mentions choice as a way of
de-emphasizing the clients autonomy by linking it to consequences the client does not desire and cannot control at this point.
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Somewhat MI-Consistent:If Icould have made sure that you attended the
check-in, Iwould have. But Idont have that power. You are the one who has
that power.
This statement is somewhat MI-consistent. The provider emphasizes the clients autonomy by clearly stating that the client is the one who has the power
to decide whether to attend check-in meetings. The provider also expresses
compassion by stating, If I could have made sure that you attended the
check-in, I would have. However, by focusing primarily on what has
already happened the provider is less likely to move the client toward positive change from that point forward. Moreover, given that the client did not
like the consequences of the missed check-in, this emphasis of autonomy
could be interpreted by the client as an attempt to blame the client for missing the appointment.
MI-Consistent:The conditions of your probation are set by the court, so my
hands are tied as far as what the consequences will be. Iknow this is disappointing for you because youd been doing well for so long. As you know from
experience, your behavior from this point forward can have a big influence
on what happens next, so now it is really in your hands to decide whether its
worth it to do things that will incline the court to be lenient or not.
This response is MI-consistent because the provider emphasizes the autonomy the client does have to try to do things that will impress the court and
may result in leniency. The provider also offers information about consequences in an objective fashion and reflects the clients inferred emotional
reaction to the possibility of being sent back to prison, which demonstrates
empathy.
Proposed Strategy 3:Initiating Discord

Another useful, MI-consistent strategy for working with clients with legal
involvement described by Stasiewicz, Herman, Nochajski, and Dermen (2006) is
initiating discord. This strategy addresses a problem commonly encountered in
clients with legal involvement:a strong sense of discord (formerly termed resistance) at the outset of an interaction with a provider (before the provider has
even initiated a conversation with the client). This sense of discord may have
nothing to do with the provider per se, but rather the clients sense that the provider is part of a system that has wronged or harmed the client in some way. The
difficulty a provider may face in addressing this discord is that the client may
not feel comfortable expressing their anger or resentment at the outset of the
session. Aclient may in fact deny that anything is bothering him or her if asked
directly by the provider. However, until the client has an opportunity to express
the thoughts and feelings driving the discord in their relationship with the provider, it may be difficult, if not impossible, for the client and provider to move
forward in a meaningful way.
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Consistent with prior terminology used to describe discord (Miller & Rollnick,
2002), Stasiewicz and colleagues (2006) termed the strategy they developed to
address this type of discord initiating rolling with resistance. As the name
implies, what this strategy entails is proactively creating an opportunity for clients to express their anger, resentment, etc. early on in their contact with the
provider. This allows the client and provider to work through it and more quickly
focus on whether and what changes the client would like to make. In their work
with DWI (driving while intoxicated) offenders, Stasiewicz and colleagues
described initiating a session by empathically offering as possible topics for discussion several of the most common discordant statements they encountered
when working with DWI clients. Items on this list might include the substantial
monetary costs associated with a DWI conviction (e.g., attorney fees, treatment
costs, impound fees, lost wages) or a belief that the legal system is harsh on DWI
offenders relative to other impaired drivers (e.g., those who text and drive). Not
only does this strategy create an opportunity for clients to get their negative feelings off their chest early in the interaction, it is also a way to express empathy; it
gives clients a sense that the provider has some understanding of the experience
of receiving a DWI.
The decision to use this strategy should be based upon a providers experience
in a particular context as well as indications from the client that discord is present (e.g., a feeling of tension in the room; a hostile voice tone or sarcastic comments from the client; quiet, passive responding). Providers who work in settings
where clients almost invariably express anger, frustration, resentment, or similar
reactions in their early interactions with providers might find it very useful to
develop a list of the most commonly voiced concerns and initiate discord at the
outset of initial encounters. This may include settings where legal involvement
is not the source of discord. For example, providers in clinics or agencies with
long wait times, older facilities, crowded waiting rooms, inconvenient hours, or
other factors likely to arouse feelings of frustration or resentment in many clients
might find this as a useful strategy.
Example:MI-Consistent/Inconsistent Initiating Discord
strategies for initiating discord:
Client Statement:Well Im here. Whats next?
MI-Inconsistent: Listen, you and I are going to be working together for
the next 12 weeks, and this is going to go a lot more smoothly if you lose the
attitude.
This statement is likely to increase discord between the client and provider in a very MI-inconsistent fashion. Rather than proactively creating
an empathic, supportive opportunity for the client to discuss negative
thoughts and feelings he or she might have about working with the provider, the provider seeks to proactively shut this discussion down by labeling the clients thoughts and feelings as a bad attitude and issuing what
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might be interpreted as a veiled threat about what might happen if the client
expresses negative thoughts or feelings. This is an example of not resisting
the righting reflex (see c hapter2).
Somewhat MI-Consistent:Well, during todays visit we are going to review
the circumstances of your DWI arrest and discuss the goals of this program.
Does that sound okay to you?
This statement is somewhat MI-consistent. This statement is somewhat collaborative in that in response to the clients question, Whats next? the
provider presents the session plan and then offers the client an opportunity to either agree or disagree with the plan. However, the provider is not
emphatically attuned to the clients obvious sense of frustration and does
not create an opportunity for the client to express that frustration openly.
Instead the provider seeks to move ahead with the session as planned in
spite of the clients obvious reluctance.
MI-Consistent: There a few things we need to get done today, but before
we dive into that, Id like to check in with you. A lot of times people who
are referred to this treatment have a lot on their minds. Some are pretty
upset about what seems like bias in the legal system against them, others
feel betrayed by a friend or neighbor who called the police, others think the
amount of time at work they lose and the fees they have to spend to attend this
group are a little ridiculous, and still others feel very anxious about what this
means and what will happen to them because theyve never been in trouble
before. What, if any, of these thoughts or concerns do you have?
This response is MI-consistent, because the provider does resist the righting reflex and instead empathically notes from the clients words and tone
that she may not be pleased with meeting with the provider. Then, in a supportive, empathic fashion, the provider offers information (a list of potential
sources of discord) and an open question that invites the client to express
his feelings or concerns.
No-shows and non-adherence are perhaps among the most ubiquitous clinical
challenges faced by providers across disciplines and settings. There are a broad
range of MI-consistent strategies that may help providers reduce no-shows and
non-adherence by helping clients increase their readiness to change. Clients who
are involved with the legal system or otherwise coerced into a helping relationship are also often less ready to change, and MI-consistent strategies can be valuable in that context as well. Effectively working with clients who are less ready to
change can be facilitated by viewing readiness to change as a process of different
stages (e.g., He hasnt decided for sure whether hes ready to change) through
which a client may progress, rather than a static characteristic of a particular
Table4.2.Summary of Motivational Interviewing Strategies for Clinical

Challenges with Less Ready Clients
Clinical Challenge
Suggested MI Strategies
No-Shows:
MI-consistent referrals: Making referrals in a collaborative

fashion and only after having sufficient information about
the clients preferences and motivations to know that a
referral is a good fit.
Frequently
rescheduling
appointments
(sometimes at
the last minute)
or not attending
regularly scheduled
appointments.
Giving information:Providing information in an engaging

and objective fashion about the nature of the referral and
appointment policies.
Planning:Engaging the client in a collaborative conversation
about how client will achieve his or her goals.
Emphasizing autonomy:Explicitly communicating that
ultimately it is the clients decision whether he or she attends
a recommended or required visit
Non-adherence:
Arriving to
appointments late,
no-showing, or
not following a
treatment plan.
Evocative questions:Using questions aimed at genuinely

understanding the clients concerns, motivations, and
potential approaches to change.
Scaling questions:Using a 010 scale to elicit how important
and confident a client feels in relation to change.
Looking forward:Guiding client to look forward in their life
and relate change or no change to potential outcomes in the
future.
Revising the change plan:Stepping back, reviewing, and
renegotiating the plan for change focusing on the discussion
of multiple versus a single change option.
Emphasizing personal control:Explicitly and genuinely
highlighting clients right to choose to do what they think is
best for them.
Legal involvements:
Seeking services
because of a court
mandate, referral,
or suggestion from
an attorney.
Giving information:With permission, provide objective,

clear, and explicit information about your role in regard to
the legal system, and confidentiality and its limits.
Emphasizing autonomy:Emphasizing the aspects of the
clients if that are within his or her control when he or she
perceives loss of control.
Initiating discord:Proactively creating an opportunity for
client to express anger, resentment, or other concerns about
the referral.
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client (e.g., Hes just stubborn). Doing so can enhance your understanding of
client change (or lack thereof) and help you tailor your interventions or the delivery of your interventions to the clients level of readiness. The important thing
to recognize is that clients are less ready for a variety of reasons, and utilizing
some of the MI-consistent strategies outlined in this chapter can help you meet
clients where they are in their change process and help them to become more
ready to change. Table4.2 summarizes the clinical challenges and suggested MI
strategies.
Loss of Momentum
People changing often encounter faster and slower progress toward the change
goals, increases and decreases in momentum, setbacks, brief returns to problem behaviors, and even complete return to problem behavior. As outlined more
fully in our discussion of Prochaska and Diclementes (1983) stages of change
in c hapters 2 and 4, clients cycle through these stages of readiness to change.
Thus, simply because an individual enters an action or even a maintenance stage
does not ensure they will not return to a previous stage of readiness to change.
Although not a specific stage in the readiness to change model, recycling and
relapse often accompany any discussion of the model (Connors, DiClemente,
Velasquez, & Donovan, 2013).
Quick Reference
Relapse
Relapse and recycling:Apart of change in which clients may return to previous
stages of change (e.g., contemplation) and also reengage in problem behaviors.
Diverse reasons exist for waxes and wanes in client progress. These reasons
can range from changes in importance and confidence, to external barriers
like decreases in family support, to entering the change process with unrealistic expectations. Some of these reasons are more manageable for clients and
some are less controllable. Whether controllable or not, it is important to recognize shifts in momentum toward a change goal and to further recognize that
although a client has been actively changing, loss of momentum is a signal that
something has changed that requires parallel change from the MI-consistent
provider. Generally this change will be a shift from a more directive approach to
an MI-consistent guiding style. By viewing shifts in momentum as an opportunity to re-engage or recycle through the readiness to change process and adopting an MI-consistent style, a provider can help clients regain the momentum
toward change. In fact, the ability to integrate an MI-consistent style when clients lose momentum during the active change process seems to be one of the
important benefits of this approach.
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C L I N I CA L C H A L L EN G E 1:S LOW PR O G R ES S
Description
Individuals we have trained frequently express concern about clients who appear
to be motivated to change and yet progress slowly in their change efforts. This
experience can certainly be confusing and leave providers wondering exactly
why their clients are not progressing faster given their expressed desire or need
and perhaps even intention to change. You may remember from chapter2 that
change talk, in particular statements about intention, has been identified as a predictor of positive change outcomes (Amrhein, Miller, Yahne, Palmer, & Fulcher,
2003). In our experience, providers (including us at times) tend to assume that
after clients have expressed an intention to change, we have permission to adopt
an active expert role and advise clients what they need to do to change. This is
why clients come to see us, right? This assumption often leads us to develop a
plan of action or intervention for the client and then present it to the client. In
doing this; however, we fail to honor our clients autonomy and elicit their expertise to help us determine the best plan of action. We then experience concern,
frustration, and even disillusionment with our clients slow progress as we place
all of the responsibility for their progress, or lack thereof, on them.
An example from our experience might help illustrate this point. I(MM) regularly supervise advanced doctoral students providing psychological services.
Many times Ihave observed students meeting with clients for two sessions to
understand the clients concerns and treatment goals. After the second session
these students sit in the clinic work space and write a treatment plan to present
to the client at the third session. Several sessions later, Ive had these students
approach me with frustration that the client is not making progress on the treatment plan. Itend to respond in these situations with a simple question, How
much of the plan is theirs and how much of it is yours? The point in this story
and in my questioning of my supervisees is to emphasize that, from an MI perspective, we need to be collaborative and evocative in developing a change plan.
Conceptualizing slow progress as evidence of a need to reassess motivation and
reevaluate the change plan may help a provider to adopt a more MI-consistent
style in these situations. Miller and Rollnick (2013) and others (e.g., Westra,
2012)remind us of the need to pay attention to shifts in motivation and even the
reemergence of ambivalence as clients progress through treatment. There can be
various reasons why progress is slow or slows down ranging from development
of the wrong plan, to unexpected difficulties with various aspects of the change
plan, to life events and barriers that may take precedence over changing.
Example:Joel is a 40-year-old man who is seeking career counseling due to
recently being laid off from his job. He worked as an accountant for a local
bank and is a certified public accountant. In meeting with his career counselor he was given a list of jobs for which the counselor deemed he was qualified and told to apply for each job and return in a week. Upon returning Joel
Loss of Momentum
101
informed the counselor that he applied for only one of the jobs as the others
didnt seem to meet his needs or interests in a career. At this information
the career counselor asked Joel if he wanted a job. Joel responded to this
question with a vehement declaration, Its my top priority! The counselor
responded by adding three more jobs to the list that she thought were appropriate and sent Joel on his way to return in 2 weeks. Upon returning Joel
reported applying for one of the new jobs but no others stating that they
didnt seem to meet his needs and interests. Hearing this information his
counselor became visibly frustrated and again asked if Joel wanted a job.
Joels experience is a common one when there is a schism between the plan
outlined or determined by the provider and the clients goals, needs, or preferences. One way of looking at Joels situation is that he really doesnt want a job
and is just going through the motionsperhaps for some secondary gain. Or
perhaps finding a job isnt as urgent for him as the provider thinks it is. We have
noted this perspective when medical professionals we train share their frustrations about lack of client change. They often say something like if they knew
how important or urgent it is to their health for them to lose weight they would
get on it ASAP. Although believing that change is important certainly facilitates change, it is not the only factor that should be considered when trying to
understand slow progress. An MI-consistent way to think about this situation is
that the change plan may not have captured the best strategies for changing or
something has occurred that may have led the client to be more apprehensive
about a particular change strategy. Thus, when experiencing slow progress, a
more MI-consistent approach would include evoking information from the client about the factors that may be slowing down progress.

A good MI-consistent way to discuss slow progress with clients is to step back
from being directive (e.g., offering advice, suggestions, or solutions) and use
evocative questions. The use of evocative questions in these situations helps providers elicit from clients their own evaluation of how they are progressing and
what might be getting in the way. Adopting this approach can help avoid the
expert trap and the righting reflex by keeping the relationship collaborative. It
also communicates that the provider genuinely wants to understand the clients
perspective on the situation.
evoking when clients are progressing slowly.
Client Statement:I applied for one of the five jobs you provided me last week.
Getting a job is really important to me.
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MI-Inconsistent: Securing a job is important for you and yet you only
applied for one job. Dont you think it would be important to apply for all of
the jobs Igave you?
Even though the provider begins with a reflection the response is
MI-inconsistent. The reflection has a somewhat judgmental tone, primarily because of the word only. By using only the provider is communicating that the client should have applied for more than one job. Additionally,
the question is a closed question and a rhetorical question that is likely to
engender discord versus facilitating discussion.
Somewhat MI-Consistent:I hear that finding a job is really important to
you. At the same time, you applied for one of the five jobs on the list. What
was wrong with the other jobs?
This statement is somewhat MI-consistent. The provider offers a reflection
that expresses appreciation for the ambivalence the client is experiencing.
However, rather than stepping back to learn more about the client, the provider remains focused on the jobs that were provided to learn why they
didnt work for the client. This approach could invite discord or sustain talk
versus better understanding of the clients motivations.
MI-Consistent:I hear that finding a job is really important to you. At the same
time, you applied for one of the five jobs on the list. Perhaps Igot a bit ahead of us
with the list Igave you and didnt spend enough time talking to you about your
goals and expectations. If its okay with you, Id like to learn a bit about what
worked for you and what didnt with the plan we developed for you to find a job.
This statement is MI-consistent for several reasons. The provider begins
with a double-sided reflection that highlights the clients desired goal and
compares that with the progress. There is no judgment in the reflection;
the provider simply highlights what the client has said. The provider then
admits to possibly taking an expert role and jumping ahead of the client
in the plan. This allows for the provider to then transition back to eliciting
from the client his perception of how well or not the plan unfolded. Through
this the provider communicates collaboration and wanting to understand
the clients evaluation of the implementation of the plan.
Proposed Strategy 2:Assessing Importance and Confidence

As clients progress through change plans, the importance of the change and
their confidence in their ability to make the change may wax and wane as they
are faced with new goals, tasks, or obstacles. For example, in treating clients with
obsessive-compulsive disorder, I (MM) noted that these clients often experienced reductions in importance and confidence as treatment progressed. As further outlined in chapter6, although they are highly efficacious, exposure-based
treatments for obsessive-compulsive and related disorders require clients to
complete practice exercises that can result in transient intense anxiety and other
Loss of Momentum
103
negative emotions. Thus, it is not uncommon for clients to express ambivalence

about doing new exposures in their treatment even if they have already successfully completed related exposures. In part this seemed due to their anxiety and
desire to avoidthus reducing the importance (e.g., Id rather just live with
this illness than do this treatment.). However, Ialso noted what seemed to be
a lack of confidence in the ability to do the exposure (e.g., I want to do this.
Ijust dont think Ican go through with it today.). The mantra at the treatment
facility was just do the exposure and it will get bettera common behavior
therapy response. Although the statement is true, this approach often can lead
to slower progress and impasses in treatment. By assessing importance and
confidence when progress slows, a provider can engage the client in a discussion, learn what is behind the slow progress, and even help the client resolve
any importance or confidence barriers. Remember that ambivalence can return
when someone is actively changing. One way it might present itself is through
slow or slowed-down progress.
Example:MI-Consistent/Inconsistent Reassessing Importance and
Confidence
questions for reassessing importance and confidence when clients experience slow progress.
MI-Inconsistent:So is getting a job really important to you?
This provider statement is MI-inconsistent for two reasons. The providers
emphasis on really communicates that he does not believe the clients
statement about importance. The question appears to be an accusation and
does not assess how important finding a job is for the client. This statement
by the provider is more likely to elicit a defensive response from the client
as the provider is calling out the client and challenging him. The question
is also a closed question. By asking the question in this way, the provider is
unlikely to learn about the factors that are impeding progress.
Somewhat MI-Consistent:On a scale of 1 to 10, how confident you are in
your ability to search for a job?
This response is somewhat MI-consistent. Now that the provider understands how important finding a job is to the client, he or she uses a scaling
question to assess his confidence in his ability to find a job. However, the
provider jumps to a scaling question on a different topic (confidence versus
importance) without first reflecting what the client has said. This is a missed
opportunity to express empathy. If done repeatedly, this could lead the client to believe the provider is not really interested in what he or she is saying,
or to a question and answer trap in which the client passively responds to
provider questions.
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MI-Consistent: Finding a job is something that is important to you. This

week you were able to apply for one of the five jobs on the list. Iwonder if
you can share with me, on a scale of 0 to 10, how confident you are in your
ability to search for a job. [Client response:About a 5.] So you have some
confidence to search for a job. What makes your confidence a 5 and not a 3?
MI-Consistent:Finding a job is important to you and you were able to apply for
one of the five jobs on the list. Perhaps you can tell me on a scale of 0 to 10 where
the importance of finding a job is for you at this point? [Client response:About
a 7.] So it is important to you but not of the highest importance at this time.
What would need to happen for it to be a 9 or 10 and not a 7?
These statements are MI-consistent for several reasons. The provider uses
reflection to highlight that the client was able to apply for one job on the
list while also indicating it was one of five positions. There is no judgment in these reflections and they restate what the client has said. The
providers statements focus on the client and do not introduce his own
interpretations of the situation. There is no assumption of how important
or confident the client is in the plan. Further, the questions are presented
in a way that does not imply the client is lying or that the provider doesnt
believe the client.
Proposed Strategy 3:Revise the Change Plan

Sometimes slow progress might be an indicator that the original change plan
that was developed (and to which the client committed) may not have been the
best possible plan. This can be the case for several reasons:perhaps the provider
was not fully collaborative, or all of the possible options and barriers were not
considered, or the client didnt envision what it would look like when they began
the plan. Regardless of the reason, slow progress by a client may signal the need
to revisit the change plan to determine what aspects of the plan, if any, need to be
revised to facilitate change. Stepping back to review the change plan when progress is slow communicates to clients that the provider and client are in this process together and that the provider is genuinely committed to helping the client
develop the best personal plan of action. This approach is more MI-consistent
than asking, Why arent you working on this plan? You agreed to it. Remember
from chapter2 that we need to respect the expertise and autonomy of the client
and we want to work with them to determine what change is best and how it is
best to change for each client.
Example:MI-Consistent/Inconsistent Revising a Plan
revising of the change plan.
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MI-Inconsistent:This plan doesnt seem to be working for you. Is the plan

wrong?
The provider acknowledges that the plan may not be working for the client.
What makes this statement MI-inconsistent is the closed question. Remember
to be MI-consistent providers want to use more engaging and eliciting questions. Aclosed question rarely accomplishes this goal. Additionally, the question has the potential to engender some defensiveness in the client.
Somewhat MI-Consistent:You accomplished part of your plan and struggled
with other parts. What needs to change to make the plan work better for you?
The provider affirms that the client made some accomplishments in the
plan which is MI-consistent. However, the provider also emphasizes the difficulty the client had with the plan by closing the reflection with that point.
This reflection combined with the question could communicate some judgment, though subtle, about the clients efforts and invite discord.
MI-Consistent:You accomplished part of the plan this week. In moving forward it might be helpful to revisit the change plan to see if there are things that
need to be added, removed, or revised to strengthen it for you.
This provider statement has several aspects that make it MI-consistent.
The provider reflects the clients statement about progress on the plan.
Additionally, there is a strength-based emphasis (i.e., you accomplished).
Placing emphasis on what was accomplished potentially reduces the chance
of eliciting defensiveness. Further, the provider raises the idea, without any
judgment, of looking at the plan to see what might need to be changed.
The statement also attempts to engage the client in the process of reviewing
the plan. See the Evaluating the Current Plan box for some questions you
could use in reevaluating the change plan.
Evaluating the Current Plan
What have you learned from trying to implement this plan?
What aspects of the plan are working?
What parts of the plan are not working?
How is the plan helping you meet your goals?
What should we add/remove from the plan?
What should we revise in the plan?
Proposed Strategy 4:Emphasizing Personal Control

Ultimately what clients decide to do with their change plans is up to them. As
we have mentioned multiple times in this book, we cant make people do what
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they do not want to do. This fact also applies to the speed at which someone
progresses on her or his change plan. Thus, it is important for us to remember, in
remaining MI-consistent, that clients are in control of their change and the pace
at which they change. In other words, we need to recognize that it is the clients
change timetable and not ours. Ultimately, it is up to our clients how fast or slow
they change. Thus, we need to be mindful of the importance of client autonomy
and personal control when client progress is slow to keep us from pressuring
clients. It is also something of which clients should be reminded in the face of
slow progress.
Example:MI-Consistent/Inconsistent Emphasizing Personal Control
emphasizing personal control for slow-progressing clients.
MI-Inconsistent:It is your choice how many jobs you apply for but we need
to get you a job.
The attempt to emphasize personal control was thwarted by the end of the
providers statementbut we need to get you a job. This minimizes the
clients personal control and choice in the situation by expressing something that has to happen. Further, by adding the message you need to get
a job, the provider is increasing the chances the client will engage in conversation about why it is hard to get a job or when the jobs or strategies suggested will not work. In other words, this statement is likely to elicit sustain
talk and possibly discord.
Somewhat MI-Consistent: Finding a job is really important to you. Only
you can make this happen.
The provider begins with a reflection highlighting the importance of getting a job to the client and emphasizes personal control. However, the providers attempt to emphasize personal control could elicit sustain talk or
discord as there is a hint of judgment in the statement.
MI-Consistent:You are here because you want to find a job and indicated
that is really important to you. Nobody knows you and what jobs fit you better than you do. And nobody other than you can decide how many jobs you
apply for.
The provider begins the statement by reflecting the clients statement about
the importance of finding a job. Further, the provider makes a statement
that emphasizes that the client is the expert on himself and that he is in
control of his life. This includes the provider also suggesting that the pace of
finding a job is completely within the clients control and not the providers.
The provider avoids including his perspective on how many jobs the client
should apply for or how fast he should seek opportunities.
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C L I N I CA L C H A L L EN G E 2:L A PS ES A N D R EL A PS ES
Description
It is common for clients who are changing to experience a slip or lapse, an initial setback during which they return to a previous behavior that is counter to
their change effort (Marlatt & Witkiewitz, 2005). Once they experience this
setback, many clients experience a relapse or a total return to the problematic
patterns they were trying to change (Connors etal., 2013). Think for a moment
about New Years resolutions. At the start of every year, countless people flock
to fitness centers with the goal of increasing their physical activity and becoming healthier. For some this goal is actualized; however, for many others work
toward their goals tends to wane after weeks or months only to be revisited again
with the next New Years resolution. Thus, setbacks, lapses, and relapses are
common occurrences when changing. Regardless of this fact, we as providers
often become discouraged when a client lapses or relapses. As a result, we often
respond in a fashion that is MI-inconsistent, especially in some contexts where
relapse is very common. Miller, Forcehimes, and Zweben (2011) comment how
it seems strange that many treatment programs and providers respond to lapses
and relapses in a punitive fashion when setbacks are so common when changing.
Their point is a good one:if we conceptualize slips and relapses as part of the
change process, why not respond in a supportive fashion that aims to reengage
the client in the change process? We certainly do not respond in a punitive fashion when someones cancer reoccurs.
Example: Elaina is a 35-year-old woman who is married and has three
children. She gained 75 pounds when she was pregnant with her third child
3years ago. Then she learned that she had hypertension and her physician
recommended she lose weight and change her lifestyle. About a year ago she
began to work with a dietician, a personal trainer, and a behavioral specialist to develop a healthier lifestyle. For 7months Elaina has been successful
in increasing her physical activity and modifying her diet, which led to a
25-pound weight loss. However, she recently stopped exercising and returned
to old eating patterns during the holiday season. She also began to avoid her
counseling sessions with her team. When she finally talked with her behavior
specialist, she indicated she felt terrible about her relapse and that her team
would be mad at her.
Elainas experience is not uncommon when people are attempting lasting
change. One explanation for what might have happened is the abstinence
violation effect, in which clients who have made change think they fell off
the wagon by reengaging in a problem behavior (Gaughf & Madson, 2008).
Adopting a punitive stance as a provider can reinforce the abstinence violation effect and lead a client to disengage from the provider or even from
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considering reengaging in change. However, remembering the stages of readiness to change and maintaining an MI-consistent focus can certainly help
providers react and respond to these types of setbacks in clients and reengage
them in the change process. Here are some strategies for working with clients
who reengage in problem behaviors.
Proposed Strategy 1:Providing Information

Providing information about the potential for lapse and relapse can be very beneficial in helping clients appreciate the waxes and wanes associated with making
lasting change. Educating clients about the high-risk situations and discussing
them is a valuable aspect of relapse prevention (Marlatt & Witkiewitz, 2005).
However, when clients are actively making change or have sustained a change
for a period of time, there can be a tendency for providers to adopt an expert
role and actively prescribe what the client should do in high-risk situations. This
approach would be inconsistent with MI. In c hapter3 we discussed the cyclical
process of exchanging information called elicit-provide-elicit as an MI-consistent
method for providing information (Rollnick, Miller, & Butler, 2008). By using
elicit-provide-elicit, a provider can discuss the potential for lapses and relapses
and discuss what happened during a lapse or relapse event. This approach allows
the provider to explore lapses and relapses in a collaborative way that is engaging
and invites clients to be the expert commentators on their situation.
Example:MI-Consistent/Inconsistent Providing Information
providing information.
Client Statement:I dont know what happenedbefore Iknew it 2months
went by and Ihadnt exercised. Then Ijust ate all the holiday goodies ignoring
my diet plan.
MI-Inconsistent:The holidays are a difficult time for many people to maintain healthy lifestyles. You really need to remember your plan and how it can
help you avoid those temptations.
This statement is MI-inconsistent for several reasons. First, the tone of
the providers statement is somewhat judgmental and is likely to elicit
responses from the client justifying why the setback happened. Second,
the provider adopts an expert role and jumps into providing information
about relapse. Here the provider is missing an opportunity to engage the
client as a collaborator in identifying what happened that led her to resume
her eating behaviors and not exercising. Finally, the provider prescribes
what the client needs to do to avoid a relapse. However, the provider is
missing an opportunity to gauge the clients interpretation or reactions to
the information provided.
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Somewhat MI-Consistent:You ran into some difficulties with your plan over
the holidays that you see as a setback. You may remember from past experiences that the holidays can be a particularly difficult timewe call them
high-risk situations. At these times ones health plan is particularly important. How does that information match up with your experiences?
This statement is somewhat MI-consistent. The provider begins with a
reflection that communicates empathy and understanding of the client.
The provider checks in with the client again after providing information.
However, the provider does not elicit from the client prior to providing information and decides what information to provide without first
checking what the client already knows from her experience with previous change efforts. There is a potential that the client may respond with
sustain talk.
MI-Consistent:You ran into some difficulties with your plan over the holidays that you see as a setback. From your past experiences trying to make
changes, what do you know about difficulties changing? [Waits for client response]. If Imight share with you, the holidays can be a particularly
high-risk time for folks trying to change their eating and exercise behaviors
for a variety of reasons, ranging from stress to tempting foods to being very
busy. How does that information match up with your experiences?
This statement is MI-consistent for several reasons. First, the statement
begins by reflecting the clients conceptualization of the problem, which
validates her experience. There is also no judgmental tone and the reflection
is simply reiterating the facts as perceived by the client. Next, the provider
offers some information about how the holiday season can be difficult for
a lot of people and provides some potential reasons why this is the case.
Finally, rather than telling the client what she needs to do, the provider elicits the clients interpretation of the information. This approach can reduce
the emotionality of the situation, communicate a matter-of-fact mind-set
and facilitate a focus on where to go from here.
Proposed Strategy 2:Reassess Importance and Confidence

Recognizing lapses and relapses as a natural part of the lasting change process
can help a provider refocus on building motivation for reengagement in active
behavior change. Thus, a provider may need to revisit the clients motivation
for changing (Miller etal., 2011). One approach to begin this discussion is reexamining how important the change is to client and how confident they feel
in their abilities to change after a lapse or relapse. In other words, a provider
can use the importance and confidence questions to begin assessing whether
something has changed for the client that may have led him or her to resume
problematic patterns.
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Example:MI-Consistent/Inconsistent Reassessing Importance and

Confidence
scaling questions for reassessing importance and confidence clients who
lapse or relapse.
Client Statement:I dont know what happened. Before Iknew it 2months
went by and Ihadnt exercised, then Ijust ate all the holiday goodies, ignoring my diet plan.
MI-Inconsistent:So is your diet and exercise still important to you?
This provider statement is MI-inconsistent for two reasons. First, the use
of a question like this, especially in the context of a relapse, is somewhat
judgmental and is likely to engender discord as it can be perceived as an
accusation versus assessing how important resuming change is to the client. Second, this is a closed question, and given the tone of the question
may likely elicit a short response versus a longer response. Thus, by using
this question the provider has missed an opportunity to engage the client in
exploring her hesitancy to change or identify why the importance of changing has reduced.
Somewhat MI-Consistent:How important is changing to you right now?
This statement is somewhat MI-consistent. The provider offers an open
question that invites the client to share her perspectives. However, by jumping straight to a question, the provider misses an opportunity to express
empathy, provide support, and/or affirm a client who likely feels disappointed in herself. Additionally, while the open question used is not necessarily a bad question, in this particular case it may imply that the provider
believes the clients lapse may be an indication that she is not serious about
change. This could lead to defensiveness.
MI-Consistent:You had a lot of things come up in the past few months with
the holidays that have gotten in the way with your change plan. Iwonder,
for you at this point on a scale of 0 (not at all important) to 10 (the most
important thing) how important it is to you to resume your change? [Client
response:About an 8.] So it is fairly important to you to resume changing.
What makes the importance an 8 and not a 6?
MI-Consistent:You had a lot of things come up in the past few months
including the holidays that have gotten in the way with your change plan
and left you discouraged. At this point on a scale of 0 (not at all confident) to
10 (completely confident), how confident are you in your ability to resume
your change? [Client response: About a 4.] So while it is important to
you, perhaps based on your recent experience, you are not as confident in
resuming change. What would need to happen for it to be a 7 and not a 4?
These statements are MI-consistent for several reasons. First the statements
begin with a reflection that validates the clients experience with the relapse.
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They are matter of fact with no judgment and simply restate what the client has experienced with an added emotion. Next, the statements focus on
assessing the clients perspective of how important change is and how confident she feels in resuming change. There is no assumption that the client is
ready or confident in resuming change. By using a scaling question to focus
on the importance of the behavior the provider gets a better sense of where
the client is at in resuming her change or not. Finally, the follow-up question is likely to guide the client to provide change talk by discussing why
resuming change is important and how she can become more confident.
Proposed Strategy 3:Looking Back

Once clients relapse, they may be preoccupied with the relapse and perhaps
whatever has changed that has led to the return to problem behaviors. Possibly
their motivation has changed because they do not recall what things were like
while they were actively changing. Therefore, as part of building motivation to
reengage in change after a relapse, it may be valuable to look back to the time
when the client was actively changing and compare that to their current state.
Example:MI-Consistent/Inconsistent Looking Back
looking back for clients who relapsed.
Client Statement:I dont know what happenedbefore Iknew it 2months
went by and Ihadnt exercised. Then Ijust ate all the holiday goodies, ignoring my diet plan.
MI-Inconsistent:Do you remember what it was like when you were actively
changing before you relapsed?
This statement is MI-inconsistent because the provider uses a closed question. The question also could be perceived by the client as judgmental.
Additionally, the provider falls into the labeling trap by using the word
relapse. Labeling words can elicit discord from clients who feel judged.
Somewhat MI-Consistent:You are frustrated that after you made progress
you had a return to previous behavior. Perhaps we can take a moment to look
back on what led up to the setback in your plan.
The provider offers a nice reflection to communicate empathy. Traditionally,
however, the looking back strategy in MI focuses on a time when the client
was not engaged in the problem behavior. Thus, the application of looking
back in this way is only somewhat MI-consistent, as it might focus the client on talking about the problem versus what it was like when the client was
changing so she can regain her motivation.
MI-Consistent: You are frustrated that after making much progress you
stopped exercising and started eating the holiday goodies. Iwonder if we can
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take a moment to look back to when you were following your exercise and
eating plan to see if it gives us any clues about how you might best be able to
get back on track now should you want to.
provider reflects the clients feelings about the relapse. In this reflection
the provider uses the clients own words and avoids labeling the behavior.
The provider uses looking back in an MI-consistent way by looking back
to when the client was not experiencing the problem to compare it to her
current state.
Proposed Strategy 4:Decisional Balance

Given that a lapse or relapse is a sign that clients likely shifted in their readiness
to change, it may be valuable to explore the pros and cons of changing or continuing problematic patterns. Remember from chapter3 that an MI-consistent
approach to decisional balance involves exploring all sides of the change versus
advocating for or focusing on the pro-change side of ambivalence. Pro-change
advocacy by the provider will place clients in a position to advocate for the status
quo. Thus, even though clients have been successfully involved in maintaining
change, we need to recognize that something may have occurred to tip the scale
in favor of resuming problematic patterns. For instance, Miller and colleagues
(2011) suggested that a clients successful change of one problem (in their example, substance use) can lead to the realization that other problems exist. This
realization could lead to falling back into problem patterns. Therefore, you may
need to guide the client through reevaluating changing or not.
Example:MI-ConsistentInconsistent Decisional Balance
decisional balance for a client who has relapsed.
MI-Inconsistent:So you had a relapse and it will be important to get back
to your plan so you can continue losing weight and keep your blood pressure
under control. Not resuming change will only make your health worse.
This is definitely an attempt at discussing the benefits of change and negatives of not changing; however, it is MI-inconsistent. The provider has
adopted an expert role and is providing the reasons why resuming change is
beneficial and why not changing is a problem. This response will likely place
the client in a position to defend not changing by expressing the benefits of
staying the same and the cons of changing. In other words, the provider is
arguing for change, which is MI-inconsistent.
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Somewhat MI-Consistent:You are concerned about resuming some behaviors you are trying to change. What are some of the pros and cons to resuming
those behaviors?
This response is a somewhat MI-consistent attempt at a decisional balance.
The provider begins with a reflection that expresses understanding and
empathy. However, in exploring the decisional balance the provider only
elicits the pros and cons of resuming problem behaviors and ignores the
pros/cons of resuming change. This approach may guide the client to only
discuss the problem behaviors and avoid addressing change.
MI-Consistent:You had a brief period of time where you resumed some of
the behaviors you were changing. That concerned you. What might be some
of the benefits and drawbacks of staying the way you are now? What might be
some of the good things and not-so-good things about resuming your change
efforts?
This response is MI-consistent for several reasons. The statement begins
with a restatement of what the client said. The statement also added that
the client was concerned about the situation, which emphasized the unspoken emotion in the clients statement. The provider then facilitates the decisional balance by first asking about the client staying the way she currently
is in her change effort. Next, the provider asks the client about resuming
her change efforts. At no time does the provider advocate for one side or the
other (i.e., changing or staying the same), which is an important feature of
a decisional balance.
Proposed Strategy 5:Eliciting and Affirming Strengths

There can be a tendency when clients experience a lapse or relapse for them to
focus on the mistakes they made leading to the setback, which can result in negative affect and more avoidance (DiClemente, 2003). However, before the lapse or
relapse they were actively making changes. Therefore, there likely were strengths
exhibited and successes achieved. Although a provider will probably eventually
need to discuss the situation that led to the lapse or relapse, it is also valuable to
elicit from the clients their successes and what strengths helped them in their
change efforts.
Example:MI-Consistent/Inconsistent Eliciting and Affirming Strengths
eliciting and affirming strengths for clients who relapse.
MI-Inconsistent:You didnt stick with the plan. What happened?
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This type of response is commonly used by providers in an attempt to better

understand a relapse. However, the provider is not commenting on the clients success and not eliciting strengths from the client. Additionally, while
the intention may be to be supportive, this type of response could leave the
client feeling more discouraged. It clearly communicates a failure in progress. Further there is the potential that the provider commenting on the success could lead to a response from the client focusing on the setback. Finally,
the focus on what happened can lead the client to focus more on the problem
that lead to the relapse including her deficits versus eliciting strengths.
Somewhat MI-Consistent:You seem a bit discouraged in your behavior the
past few months. It could happen to anyone. Dont be too hard on yourself.
Iknow you can get back in there and do it again!
This statement is somewhat MI-consistent. The provider begins with a
reflection that expresses empathy. The provider then seeks to affirm the
client. However, rather than commenting on the clients strengths or past
successes, the provider focuses on his or her belief that the client is capable.
This sort of cheerleading is an example of the righting reflex. This response
is likely to elicit the opposite of change talk from the client in an attempt to
correct the provider.
MI-Consistent:You seem a bit discouraged in your behavior the past few
months. At the same time you made the decision to come back here which
suggests persistence. Perhaps you can share with me what you learned about
yourself during the seven months when you were very successful with your
plan?
This statement is MI-consistent for several reasons. First, with the statement
reflects an emotion the client experienced as a result of the relapse. Next,
the provider affirms the clients return. Finally, the provider seeks to elicit
from the client her strengths and what she had learned about her success in
making a change prior to the relapse.
Proposed Strategy 6:Reframing

A return to problem patterns can also be seen by clients, and some providers, as
a failure in the change effort. This view can lead to a variety of emotional, cognitive, and behavioral responses. Emotionally clients may feel guilty, sad, and
anxious. Clients may also think of themselves as failures or that they can never
change their problems. Behaviorally, clients may avoid professionals who were
involved with their change initiatives. Unfortunately, these emotional, cognitive,
and behavioral responses are more likely to entrench clients in not changing.
Reframing what a lapse or relapse is can help to facilitate different emotional,
cognitive, and behavioral responses that are more conducive to changing. In fact,
Miller and colleagues (2011) suggest referring to a lapse or relapse as a behavior
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or choice. As we mentioned earlier, conceptualizing a return to problem behaviors as a natural part of the change process can help you and clients reframe the
setbacks in a way that can help you better understand the setbacks and problem
solve what to do next.
Example:MI-Consistent/Inconsistent Reframing
reframing for clients who experienced a relapse.
MI-Inconsistent:You had a relapse. That is a normal part of changing.
This statement represents an attempt at reframing because the provider
indicates the relapse is part of changing. However, it is MI-inconsistent
because the provider uses the term relapse, which is a label, thus falling
into the labeling trap. Using a label such as relapse could evoke discord
from in the client. Additionally, the provider takes on an expert role in
that the provider assumes he or she has a full understanding of why the
client is having problems without seeking to evoke additional information about how or why the client got off track.
Somewhat MI-Consistent:In my experience setbacks are a natural part of
changing, and Ithink it is great that you came in today as it shows me how
committed you are to making a lasting change. Iam proud of you for that.
This response is supportive and a reframe of the relapse and may appear
MI-consistent. However, it is only somewhat MI-consistent for several
reasons. First, the provider falls into an expert trap by offering information without emphasizing the clients personal control or announcing or
inviting the sharing of information. Additionally, the provider violates
the rules for affirmations by using I and communicating a message that
you have pleased me.
MI-Consistent:Thank you for coming today. You recently chose to step away
from your change plan and became discouraged in light of 7months of success. It seems to me that your situation provides us a good learning opportunity. What are your thoughts about that?
This statement is MI-consistent for several reasons. First, the statement
begins with an affirmation by reframing the client showing up as a positive
given the relapse. Next, the provider avoids labeling and emphasizes that
the client made a choice which highlights personal control. Finally, by suggesting that the provider and client have a learning opportunity reframes
the relapse as a part of the change process from which they can learn.
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C L I N I CA L C H A L L EN G E 3:OV ER LY A M B I T I O U S
E X PECTAT I O N S
Description
A type of challenge that can influence momentum and can be uniquely demanding is the client with overly ambitious expectations. Clients may have expectations that changing will require little effort or that there is a magic cure or
technique that they can use to change. When watching television, you can see
advertisements for a variety of quick-change tools ranging from clothing that
melts away fat to energy-increasing or weight-reduction pills to exercise equipment that require minimal actual physical activity to get back that high school
body. For these reasons, as well as many others, many people are seeking change
initiatives that require little effort to change. Thus it is not surprising that we are
often asked, What do Ido with a client whose goals are unrealistic or unattainable in our work together?
The client with overly ambitious expectations poses an interesting dilemma for
many providers. Providers may feel a strong urge to educate that client and provide suggestions for more realistic goals based on their knowledge, experience,
and understanding of the research related to changing a particular problem. For
many clinical approaches this would be perfectly appropriate. We remember our
clinical training and the rules for developing change goals, especially the rule for
keeping goals realistic and manageable to foster success. However, adopting this
expert role is inconsistent with MI. In fact, informing clients that their goals are
unrealistic or less likely to be obtained and prescribing alternate goals may actually reduce client motivation rather than helping them to develop more attainable change goals. Thus, the dilemma is how to be MI-consistent and to help
clients manage their expectations for change, especially when they are overly
ambitious and unrealistic.
Example:Brandy is a married woman who initiates individual therapy with
concerns about her marriage and lack of communication with her husband.
She has been married for 10years and reports that her relationship with her
husband has become increasingly worse since the couple had three children.
Specifically, Brandy reported that when she tries to initiate conversation with
her husband he becomes nonresponsive and withdraws from her even further. She has read several relationship books and has not found the perfect
solution. Therefore, she has entered therapy to learn the best way to get her
husband to engage with her. She wants the therapist to provide her with the
method to solve her relationship problem.
As psychologists, we often encounter clients who have certain expectations
about what we can offer to help them change. These expectations often relate
to what we [the provider] are going to do to change them. We can certainly
appreciate where this expectation comes from as many medical interventions,
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especially those for acute illnesses, rely primarily on a health care worker doing
something to fix a problem. However, this model is generally not applicable to
prevention and management of chronic illness and other more complex problems. The best solution to these types of problems is rarely achieved by a provider
just doing something to the client. Instead, the solutions requires clients to do
something to change.
Example:Earl is a single father whose son Craig, age 10, was diagnosed with
asthma 3years ago. They are seeking counseling at the referral of Craigs physician as he is not managing his asthma very well and has been admitted to
the hospital three times in the past 6months for asthma-related problems.
Earl reports that Craig is not adhering to medical recommendations for managing his asthma and he is at a loss for what to do with Craig. Earl reports
that he works 10 to 12 hours per day and that he is not available to help Craig
keep track of his medications or monitor all of his behavior. Earl figured he
would bring Craig for counseling as that would help straighten him out and
get him to follow medical directions.
Finally, based on our societys focus on the quick fix clients may have unrealistic expectations about outcomes associated with their change and how quickly
positive change will occur. They may think that by losing weight their relationships will improve or that simply attending nutrition counseling will cure their
diabetes.
Example:Steve is diagnosed with obesity, hypertension, and diabetes. He has
had difficulties managing his weight since he was a little boy and has been
under the care of his physician for the past 5years. Steve, like many other
people, has dieted on and off throughout his life, losing some weight only to
gain it back plus some additional weight. Steve has become increasingly concerned about his weight and the associated health effects as he recently had a
mild heart attack. In fact, he has expressed his commitment to losing weight.
However, his expressed goal is to lose 50 pounds in the next month as he
wants to lose 150 pounds by his birthday in 3months. He is seeking guidance
from a weight loss specialist on how best to meet this goal.
Similarly, individuals who have made some progress in changing may overestimate what their progress means and decide that they are have completed
change and are cured. Expectations that small gains equal complete cure can
complicate that persons change initiative.
Example:Shelia is early in recovery from a drug addiction that she has struggled with for 7years. She has been in a residential substance abuse treatment
program and hasnt used in 3 weeks. Since entering the program, Shelia has
been engaged in the treatment and is showing signs of recovering physically
from her addiction. Shelia is making good gains in treatment and recognizing
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how she is improving. In a recent conversation; she stated that she believes
she now has mastery over her addiction (often referred to as the pink cloud
effect). She indicates that since she is doing well she wants to spend more
time away from the treatment facility.
Whatever the reason for clients developing overly ambitious expectations
about change, it seems to create a unique challenge to remaining MI-consistent.
This challenge involves how to remain MI-consistent and at the same time help
clients develop more realistic expectations for change initiatives. In part, this
challenge arises from the righting reflex (see c hapter 2) which causes providers to have a natural tendency to want to correct clients. Thus, one important
thing a provider can do to remain MI-consistent in working with unrealistic
expectations is to resist the righting reflex. The following are some strategies that
can help a provider resist the righting reflex and remain MI-consistent when
addressing unrealistic goals.
Proposed Strategy 1:Asking Permission to Provide

a Concern
When discussing an unrealistic goal in an MI-consistent fashion, it is imperative
that the provider not directly assert his or her expert status by rejecting the clients goal or by offering a new goal. Many providers may feel compelled to jump
to providing facts about change and education about the change process as a
strategy for helping clients modify their expectations. In fact, some approaches
to helping call for this education at the outset of any change initiative or goal setting. In contrast, MI encourages clients to remain empowered while negotiating
their change. Directly educating clients may foster a climate of passivity in the
client-provider interaction. However a provider can certainly share information
or even a concern and remain MI-consistent.
As discussed in chapter 3, information can be shared with clients in an
MI-consistent way. First, a provider can be MI-consistent by asking permission to
share some information or announcing that he or she has some information that
he or she would like to share. Whether the provider asks permission or announces
that he or she would like to share some information, the provider is communicating that he or she values the collaborative relationship with the client, accepts
their opinions about the process of change, and wants to be engaged with the
client as a partner in the change process. Another MI-consistent approach to providing information is to emphasize the clients personal control to decide what
to do with the information provided. In addition to communicating dedication
to collaboration, emphasizing personal control communicates that the provider
accepts the client and respects his or her autonomy to decide to do what he or she
thinks is best.
Loss of Momentum
Example:MI-Consistent/Inconsistent Sharing Information or Concern

strategies for sharing information or a concern.
Client Statement: I believe I have really progressed in treatment and am
ready to spend more time away from the facility. Ihave this addiction under
control now.
MI-Inconsistent: You have been here for three weeks and you have made
progress. Physically the drug has finally been eliminated from your body and
you are feeling better. There is a lot of work you need to do to more fully
recover from your addiction and more time away from the facility puts you
at risk for relapse.
This statement provides the client with information about the physiological
aspects of recovery and that recovery is an ongoing process that takes time.
Although it is not overly confrontational, it is MI-inconsistent and likely
could engender discord. In particular, the provider adopts the role of an
expert who is imparting the correct knowledge about the situation. The
likelihood that the client will push back against this statement is high.
Somewhat MI-Consistent: You have made some progress and are feeling
good about your success in treatment. One thing that concerns me is that it
is common for clients to feel mastery over their addictions early in treatment
and want to take more time away from the facility. Does that seem to fit with
your experience?
This statement is somewhat MI-consistent and reflects a comment often
offered by supportive providers. However, it is not fully MI-consistent
because the provider does not announce the offering of information or seek
permission. Similarly, the provider attempts to elicit a client response to this
information with a closed question.
MI-Consistent:You are noticing some improvements in how you feel and
in your treatmentso much so that you feel ready to spend more time away
from the facility. If it is okay with you, Iwould like to share some information about the recovery process for your consideration. [Waits for client
response]. One thing that is common in early recovery is a sense of mastery
over ones addiction when you begin feeling better physically. While it is a
sign of improvement, Iget concerned for my clients as this feeling can lead
to decisions, like ending treatment, which can increase risk for resuming the
addiction.
This statement is MI-consistent because the provider begins by reflecting
the clients statement, which communicates empathy. Next the provider
asks for permission to share the information and emphasizes the clients
personal control to decide versus simply providing the information as an
expert. Finally, the provider provides the information in a non-judgmental
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way and owns the concern about the situation as his own, which also communicates compassion for the client.
Proposed Strategy 2:Use Evocative Questions

Utilizing clients expertise and eliciting from them information that can develop
more realistic expectations can be a valuable tool to remain MI-consistent. As
mentioned in c hapter2, clients are the experts on their lives and better understand their past experiences. By selectively using questions, a provider can draw
out from clients how their experiences may or may not relate to their current
expectations. By using evocative questions a provider avoids the righting reflex,
respects client autonomy, and collaborates with the client versus acting as an
expert. Clients likely have attempted similar change initiatives in the past and
have knowledge about what worked and did not work and how realistic or unrealistic their current expectations may be. Thus, by asking evocative questions the
provider can utilize the clients experiences and expertise to help the client think
more realistically about their expectations.
evoking for clients who have unrealistic expectations.
Client Statement: I believe I have really progressed in treatment and am
ready to spend more time away from the facility. Ihave this addiction under
control now.
MI-Inconsistent:Do you really think your addiction is under control?
This question is MI-inconsistent for two reasons. First, it is a closed question. Evoking questions tend to be open ended to invite the client to respond
more thoroughly and freely. Second, the question is a rhetorical question
that also has a value judgment to it. Thus, the question is highly likely to
engender discord.
Somewhat MI-Consistent:You are really committed to your recovery and
recognize the gains you have made. Based on what you have learned about
recovery in this program, what else do you need to do to recover?
This statement is somewhat MI-consistent. The provider begins by offering
a reflection of how the client is feeling about their progress in treatment.
Next the provider asks an open question to elicit information from the client about the recovery process in relation to goals. However, rather than
exploring what the client has learned from previous experiences attempting
recovery, the provider asks the question in the context of what the client has
learned from the treatment facility. This approach fosters an expert role on
behalf of the provider and the facility and communicates that they have the
expertise and not the client.
Loss of Momentum
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MI-Consistent:You are really committed to your recovery and recognize the

gains you have made. Tell me about your past attempts to at recovery and
what you know about how recovery works for you. How might that information help inform your choices at this time.
This statement is MI-consistent because the provider begins by reflecting
the clients statement, which communicates empathy. Next, rather than
providing information about appropriate recovery, the provider uses the
clients previous experience with recovery to invite her to be the expert on
her experience. Finally, the provider uses eliciting to connect the clients
previous experience and knowledge about herself to current decisions.
Proposed Strategy 3:Elicit-Provide-Elicit

An MI-consistent approach that combines the first two proposed strategies is the elicit-provide-elicit strategy. As discussed in
chapter 3, the
elicit-provide-elicit strategy fosters client engagement in sharing information
and draws out information and reactions from the client. Elicit-provide-elicit
invites clients to share their knowledge and to interpret the information/concern shared. This strategy also allows a provider to better understand what
facts and myths the client already believes about the change initiative, and
helps the provider create a better understanding by filling in the gaps or correcting misinformation. In other words, the provider knows what they client
already knows and doesnt know so the information provided can be more
focused.
Example:MI-Consistent/Inconsistent Elicit-Provide-Elicit
elicit-provide-elicit for clients who have unrealistic expectations.
Client Statement:I really believe Ihave really progressed in treatment and
am ready to spend more time away from the facility. I have this addiction
under control now.
MI-Inconsistent:What we see in the research is that it is important to help
you to learn how to better manage high-risk situations and that takes time.
This provider statement is MI-inconsistent for two reasons. First, there is no
eliciting from the client, and the provider jumps into providing information. Second, the provider does not elicit the clients response or interpretation of that information. Finally, a statement such as this is highly likely to
engender discord as it can be perceived as judgmental.
Somewhat MI-Consistent: You really want to succeed in your recovery.
Tell me what you already know about successful recovery. [Waits for client to respond]. If Imay add to your understanding, one thing we often see
that helps is learning new strategies for assisting and monitoring high risk
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situations, which includes gradually exposing people to these situations over

time as they recover. Does that make sense?
This response is a somewhat MI-consistent use of elicit-provide-elicit, but
is not fully MI-consistent because the provider asked a closed question
after providing the information. This type of question invites only a brief
response. This type of question also may subtly communicate the message
do you agree with me and could invite passivity and less open sharing of
reactions and interpretations of the information from the client.
MI-Consistent:You really want to succeed in your recovery. Tell me what
you already know about successful recovery. [Waits for client to respond]. If
Imay add to your understanding, one thing we often see that helps is learning new strategies for assisting and monitoring high-risk situations, which
includes gradually exposing people to these situations over time as they
recover. What are your thoughts about that?
This statement is MI-consistent because the provider communicates empathy and reinforces the client wanting to recover. Next, before providing
information, the provider elicits the current knowledge of the client about
recovery. The provider announces that she would like to share some information instead of jumping into providing it. Finally, the provider elicits the
clients response to the information.
Slow progress, slips, and relapses, and unrealistic expectations are challenges
that are often encountered when clients engage in behavior change. Clients
change at differing paces and there are various reasons for why client progress
may slow. Conceptualizing clients slow progress and related behaviors in an
MI-consistent fashionas a natural part of the change process, recognizing that
motivation to change can vary over timewill likely reduce your frustration
with these challenges. Many of the MI-consistent strategies we proposed can
help you and your clients step back, evaluate, and better understand what has
changed or what needs to change to help clients return to a level of motivation
that facilitates change. Our goal is that reading this chapter you will identify how
you can utilize some of the MI-consistent strategies discussed in this chapter to
help you match clients in their change process, help them better explore the slow
progress, and help them to become more ready to change. Table5.1 summarizes
the clinical challenges and suggested MI strategies.

Challenges with Loss of Momentum
Clinical Challenge
Slow progress:
Evocative questions:Ask questions to assess how clients

perceive their progress or to identify changes that are
affecting progress.
Completing
treatment tasks,
assignments, and
goals at a pace that
is inconsistent with
expressed intention
to change.
Assessing importance and confidence:Ask scaling questions

to assess if the importance of change or confidence to change
has been altered.
Revising the change plan:Step back and review the change
plan to assess if it is working. Does it relate to the clients
goals?
Emphasizing personal control:Highlight the aspects of
clients lives that are within their control when they perceive
loss of control.
Lapse and relapse:

Returning, either
temporarily or
longer term, to a
problem behavior
after a period of
maintained change.
Provide information:Seek permission and give objective,

clear and explicit information about the nature of slips and
relapse and how they relate to the change process.
Reassess importance and confidence:Elicit how the lapse/
relapse has affected importance of and confidence to change.
Looking back:Review recent change efforts to identify how
the change was achieved and maintained. Discuss how
clients can use this information.
Decisional balance:Ask about the pros and cons of
continuing the problem behavior or re-engaging in
changing.
Eliciting and affirming strengths:Identify positive behaviors
and strengths of client before the lapse/relapse.
Reframing:Re-conceptualize lapses or relapses as learning
opportunities versus failure to change.
Overly ambitious
expectations:
Asking permission to share a concern:Express your concern,

with permission, about how clients expectations impact
Expecting outcomes their change efforts.
Evocative questions:Elicit clients expertise on previous
from the change
change attempts in comparison to their expectations.
process that are
highly unlikely
Elicit-provide-elicit:Elicit clients knowledge about their
or impossible to
expectations for change, provide objective information, and
achieve.
evoke clients interpretation and reaction to the information.
Psychiatric Symptoms and

Disorders
The National Alliance for the Mentally Ill (2013) defines mental illnesses as
medical illnesses that can disrupt a persons thinking, feeling, mood, ability to relate to others, and daily functioning (p.3). Mental illnesses are also
commonly referred to as mental disorders (American Psychiatric Association,
2013), neuropsychiatric disorders (World Health Organization, 2008), and
psychiatric disorders (Kessler et al., 1994). Regardless of the terms used to
refer to them, mental disorders are very common. In fact, according to the
World Health Organization (2008) one third of the total years lost to disability
worldwide are the result of mental disorders, such as depression, schizophrenia, and alcohol use disorders. The National Comorbidity Survey Replication,
a large, nationally representative, epidemiological survey of mental disorders in the United States, found that in any given year just over one fourth of
Americans ages 18 and older suffer from a diagnosable mental illness (Kessler,
Chiu, Demler, & Walters, 2005). Thus, even providers who do not treat mental disorders very likely provide services to individuals who are experiencing
symptoms of a mental disorder. The current chapter provides guidance on
MI-consistent strategies that can be utilized to address some common clinical
challenges that arise when working with clients who are experiencing symptoms of depression; certain anxiety, trauma-related, and obsessive compulsive
disorders; or psychotic disorders.
The goal of the current chapter is not simply to provide guidance on how to
use MI to enhance treatment for these disorders. Although mental health professionals using this book will find several of the strategies described helpful
for that purpose. Instead, this chapter is written with both the mental health
professional and nonmental health professional in mind. As such, each section
includes non-technical, descriptive information about the disorders and symptoms of focus. The clinical challenges associated with each group of disorders are
challenges that might be encountered in almost any setting where MI might be
employed, from probation to health care to substance abuse treatment. Similarly,
the vast majority of MI-consistent strategies recommended could be employed
Psychiatric Symptoms and Disorders
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just as easily in helping a client with a mental disorder engage in smoking cessation or fulfillment of probation requirements as in helping the client engage in
treatment for the mental disorder.
C L I N I CA L C H A L L EN G E 1:D EPR ES S I O N
Description
Major depressive disorder and other depressive disorders are characterized by
various symptoms and associated features. In our own clinical practice of MI
and that of others we have supervised, we have found the following features
of depression can introduce particular challenges to the practice of MI:hopelessness, feelings of worthlessness or guilt, difficulty concentrating, and lack of
interest in activities. Although everyone may experience hopelessness, guilt,
difficulty concentrating, or lack of interest in activities from time to time, it is
important to note that these experiences are more intense and impairing in the
context of a depressive disorder (American Psychiatric Association, 2013). In our
work as psychologists, we sometimes talk with the families and loved ones of
those who are experiencing a depressive disorder. In many cases it seems difficult for these concerned loved ones to understand how different the experience
of guilt, for example, can be for an individual in the midst of a major depressive
episode, than it is for someone without depression. This can make it difficult for
these concerned others to understand why she doesnt just apologize and make
amendsthat worked for me. Thus, in working with individuals who may be
experiencing depression, we believe it is vitally important for providers to maintain an MI spirit. To seek to understand how a particular client is experiencing
hopelessness, guilt, difficulty concentrating, or lack of interest, and not assume
that the experience is like the providers experience or other clients experiences.
These features of depression will likely necessitate adaptations to MI regardless of whether you are a mental health provider or a provider of another type.
For example, a client who feels hopeless about the future may have as much difficulty discussing the steps she must take to satisfy probation requirements with
her probation officer as she does collaborating on a treatment plan for depression
with her psychiatrist. In this section we seek to describe the signs and symptoms
of depression that may impact a clients ability to respond to MI, and the MI
strategies that we have found most helpful in addressing these difficulties. We try
to provide this information in a manner that is relevant to mental health providers and also accessible to providers who have no background in mental health.
Hopelessness
Hopelessness generally refers to a negative perspective on the futurea lack
of optimism (Beck & Steer, 1988). Individuals who feel hopeless generally feel
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that there is something or several things about their lives that are undesirable
or untenable, and that these things are unlikely to change. It is often difficult
for individuals who feel hopeless to even imagine how life might be better or
different. These individuals may thus have difficulty engaging in MI-consistent
tasks such as envisioning (e.g., If you were successful in making these changes,
what would your life look like in five years?) and planning (e.g., What is the
first step toward getting better control of your diet?), which require this sort of
imagining. Indications that a client you are working with may be experiencing
hopelessness are presented in the quick reference.
Quick Reference
Client Utterances Expressing Hopelessness
I dont know why Ieven bother, nothing ever works out.
Until my wife decides she is willing to quit, its not like Ican do this anyway.
Example: Hopelessness. Mario is a 36-year-old, divorced father of three

who enters a tobacco cessation clinic at the urging of his primary care physician. When asked about his confidence in his ability to quit smoking, Mario
laments that hes been a smoker for 20years and hes not sure why his doctor
thinks he can quit now. He also reports that this isnt a great time for him
to try to quit, because smoking is the only thing that makes him feel good.
Proposed Strategy 1:Hypothetical Questions

Because hopelessness can interfere with a clients ability to view change as possible, it might be difficult for a client who is feeling hopeless to respond to direct
questions about how they imagine life will be after they make a change. The
righting reflex (as described in c hapter2) can tempt a provider to try to convince
a client that change is possible, but this can result in increased verbalizations of
hopelessness (i.e., the client trying to convince the provider that change is not
possible). Using MI-consistent hypothetical questions (Miller & Rollnick, 2013),
a provider can help a client work around their hopelessness to begin imagining
a life that might different and how they might achieve that change, without forcing them to relinquish their hopelessness before they feel ready or able to do so.
Example:MI-Consistent/Inconsistent Hypothetical Questions
The following examples illustrate common types of hypothetical questions:
Client Statement:It doesnt matter what Itry, Ill never be able to stop smoking.
MI-Inconsistent:I dont buy that. If you try a little harder, Im sure you can
imagine what it might be like if you quit smoking.
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This utterance is MI-inconsistent because the provider directly confronts

the client about his hopelessness, accusing him of being dishonest and
not putting forth enough effort in an attempt to push him to envision
the future.
Somewhat MI-Consistent:You sound really discouraged. Would a prescription for smoking cessation aids make you feel more confident?
This response is somewhat MI-consistent. The provider offers an
empathic reflection and then attempts to get the client to envision the
possibility that he might someday be able to get smoking. However, to so,
the provider uses a closed question, which invites only a brief response.
The question also proposes the providers solution rather than eliciting
reasons or means for change from the client.
MI-Consistent:Right now it is hard to imagine that you will ever be successful in your smoking cessation efforts. If you were to imagine that somehow it
was possible for you to quit, what might be different or better in your life?
This provider utterance is MI-consistent, because it begins with a reflection
of the clients hopelessness rather than a challenge of it. The provider then
gently, and with respect for the clients hopelessness, invites him to hypothetically consider what his life will be like if he is successful. This is a very
basic use of the hypothetical question.
MI-Consistent:Its been really discouraging to try so many times and not
have lasting success, and its even hard to envision a future without smoking.
Just for the sake of exploring this, imagine if you will, Mario, that Ihad a
magic cure that would make it possible for you to stop smoking for good. How
would your life be better or different?
This provider utterance is MI-consistent because it begins with a supportive statement and a reflection of the clients hopelessness. The provider
then uses a type of hypothetical question that is sometimes referred to as a
miracle question to invite the client to consider the possibility of change
without immediately letting go of his hopelessness. The utterance is also
MI-consistent, because the provider gives the client permission not to
imagine the miracle cure.
MI-Consistent: You dont feel very confident about your ability to stop
smoking. What would it take to make you more confident that it might be
possible?
This provider utterance is MI-consistent, because it again begins with a
reflection. The provider then goes on to invite the client to hypothetically
consider things that might favorably alter his perspective on the possibility
of change. This type of hypothetical question can be used as a follow-up to
a confidence ruler (On a scale of 0 to 10, how confident are you about your
ability to quit smoking?see c hapter 3) for clients who express limited
confidence in their ability to change.
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As the previous examples illustrate, clients who feel hopeless may have difficulty
imagining the possibility of change. There is also evidence that individuals who
experience depressive disorders may have difficulty engaging in problem solving (DZurilla & Nezu, 2007). This difficulty in identifying and implementing
solutions to important life problems may contribute to the sense of hopelessness
that seems to sometimes make it difficult for individuals who are experiencing
depression to fully engage in an MI session. Problem solving requires a series of
steps that are not dissimilar to the planning process in a motivational interview,
including setting goals, generating solutions, and making decisions (DZurilla
& Golfriend, 1971). Thus, engaging clients in an MI-consistent planning process
(see chapter3) during which clients set goals and work collaboratively with the
provider to identify a workable strategy to achieve those goals may help foster
client belief that change is possible.
The following examples illustrate how an MI provider might use planning
to help a client overcome hopelessness:
Client Statement: It doesnt matter what I try, Ill never be able to stop
smoking.
MI-Inconsistent:There is a new medication that was just FDA approved
for smoking cessation. Im going to write you a prescription. Many of our
clients report that smoking cessation is much easier on this medication than
without it.
Although the provider acknowledges the difficulty that the client has had
with prior smoking cessation attempts and attempts to instill hope by prescribing a new drug, this provider utterance is MI-inconsistent because it is
non-collaborative. The provider assumes the expert role and seeks to make
the client a passive recipient of medical advice.
Somewhat MI-Inconsistent:I have a change plan worksheet we can fill out
together to create a strategy for change. How does that sound?
This response is somewhat MI-consistent. The provider suggests that a
change plan worksheet be filled out and asks the client for feedback on that
idea. In another context this response might be very collaborative. However,
given the clients prior expression of hopelessness, the abrupt manner in
which this idea was presented conveys both a lack of collaboration and
a lack of empathy (i.e., in response to the clients statement that he cant
change, the provider essentially says lets talk about how you can change).
MI-Consistent:Right now it is hard to imagine that you will ever be successful in your smoking cessation efforts. This may or may not be helpful for you,
but some clients have found that talking very specifically about their goals
and the different strategies they might use to achieve their goals helps them
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to feel a bit more hopeful about the possibility of success. Im wondering if we

could do that now.
This provider utterance is MI-consistent, because it begins with a reflection of the clients hopelessness rather than a challenge of it. The provider
then provides Mario with information about planning as a potential strategy to increase his hopefulness. In doing so, the provider supports Marios
autonomy and the collaborative nature of the interaction by explaining
that Mario may or may not find it helpful (see full description of planning
in chapter3 and sample change plan worksheets found in Table6.4 and
in chapter4).
Feelings of Worthlessness or Guilt

Feelings of worthlessness or guilt are another common feature of depression
that may influence how clients experience certain MI-consistent strategies.
Individuals who feel worthless or experience excessive guilt may devote great
amounts of time to thinking about mistakes they have made, deficits they perceive themselves to have, ways in which they have disappointed others, and so
on. Thus, when asked by a provider during an MI-consistent eliciting process,
What are the reasons you want to make this change? they may identify numerous well-articulated, thoroughly elaborated reasons why the change is necessary.
In our experience as MI supervisors, we have found that it is tempting for providers to view these utterances as evidence that the MI is going very well and
that the client is very engaged. However, closer examination of the content of
these utterances from clients who are experiencing depression often reveals that
the provider is not helping the client identify reasons for change. Rather, the
provider is inviting clients to give voice to and even expound upon a destructive,
self-deprecating inner monologue that occupies much of their thinking. If you
think of the depressive rumination as beating oneself up you could almost
think of using MI eliciting to encourage the client to expound upon destructive
self-evaluations as giving the client a bigger paddle with which to beat himself.
Indications that your client may be experiencing feelings of worthlessness or
excessive guilt include frequent or extreme self-deprecating comments:What
is wrong with me? Im not very smart, I should know better, I dont understand why anyone would want to be around me and/or frequent or extreme
confessions:I shouldnt have been so nasty to her, I screwed up again, Im
always doing stupid stuff like that.
Example:As Mario, the 36-year-old, divorced father of three continues his
initial consultation for smoking cessation, the provider asks him why he is
considering quitting smoking. Mario looks at the floor and in a very low voice
tells the provider that he is a terrible example for his kids and he just really
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needs to get his life together or maybe theyd be better off without him. The
provider, using MI-consistent strategies, says, Tell me more about why you
think smoking is a bad example for your kids. Mario responds by explaining that he never does anything right and that he is sure his kids have no
respect for him at all, because not only does he smoke, but he also lost his job,
destroyed his marriage, and is getting fat besides.
Proposed Strategy 3:Envisioning

As noted, clients who feel worthless or experience excessive guilt may respond
to provider questions about problems or negative consequences they have experienced with self-deprecating comments that may actually hinder rather than
facilitate change efforts. Remember, it is important not only for clients to view
change as necessary, but also as possible. Given that affirmations from the provider or questions from the provider that invite the client to describe past successes or strengths may enhance self-efficacy (i.e., the clients belief in his or her
own ability to complete tasks and reach goals) (Bandura, 1977)it is reasonable
to suspect that questions from the provider that cause the client to describe
past failures or weaknesses may diminish self-efficacy. Because clients who feel
worthless or experience excessive guilt may view their past as littered with mistakes, shortcomings, regrets, and few accomplishments or achievements, it may
be useful for a provider to instead invite the client to focus on the future. In
other words, what is possible, not what has already transpired. As noted in the
preceding section of this chapter, feelings of hopelessness can make envisioning
difficult and may require the use of hypotheticals.
Example:MI-Consistent/Inconsistent Envisioning
The following examples illustrate how a provider might use envisioning
(Miller & Rollnick, 2013)to work around worthlessness or guilt.
Client Statement:I cant believe Ismoked at home with my kids. Im such a
bad father. If they get asthma or something, Iknow it will be all my fault. No
wonder my wife left me. What kind of piece of garbage father would smoke
with his kids around? It was stupid and irresponsible and Icant undo it.
MI-Inconsistent:Youve got to let that stuff go and focus on what you can
do now.
Although the provider seems to be trying to comfort the client and is coming from a position of compassion, the statement is MI-inconsistent because
the provider is in essence ordering the client to stop having those thoughts.
That is not collaborative and does not support the clients autonomy.
Somewhat MI-Consistent:The important thing is that youre here now. Lets
talk about how to approach smoking cessation this time.
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This response is somewhat MI-consistent. The provider seeks to affirm

the client and shift the focus to smoking cessation. However, by failing to
acknowledge in any meaningful way what the client has just said, the provider conveys that he or she is not interested in the clients perspective on
anything other than how smoking cessation can be accomplished.
MI-Consistent: Im hearing loud and clear that you have a lot of regrets
about smoking for so long and that a big part of that relates to how important
it is for you to be a good father. Thats really noble. Tell me how your relationship with your kids might be different if you were successful in quitting
smoking.
This provider utterance is MI-consistent, because it begins with a reflection
of the clients thoughts and feelings. The provider then goes on to affirm the
client for the importance he places on being a good father. Finally the provider uses an open question to try to elicit from the client change talk that
is hopeful, rather than self-deprecating.
Proposed Strategy 4:Affirming

Clients who feel worthless or experience excessive guilt may have difficulty recognizing or acknowledging their strengths and successes. This can undermine
their confidence in their ability to change. In working with these clients it can
be especially important for a provider to be attuned to anything the client might
be saying that could hint at positive qualities, strengths, or past successes. Often
affirmations with clients who feel worthless or experience excessive guilt will
involve reframing something the clients has presented as a weakness or failure
in a more objective and positive way.
Example:MI-Consistent/Inconsistent Affirming
The following examples illustrate how a provider might use affirmations to
overcome worthlessness or guilt.
Client Statement:I cant believe Ismoked at home with my kids. Im such a
bad father. If they get asthma or something, Iknow it will be all my fault. No
wonder my wife left me. What kind of piece of garbage father would smoke
with his kids around? It was stupid and irresponsible and Icant undo it.
MI-Inconsistent:Yes. Secondhand smoke is really bad for kids. Until you get
a handle on this, Ithink your ex-wife is doing the right thing by not letting the
kids be around you.
This statement is MI-inconsistent because the provider directly confronts
the client about his smoking. This statement also demonstrates a lack of
collaboration and compassion because the provider expresses more concern
for the clients ex-wife and children than for the client.
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Somewhat MI-Consistent:The important thing is that you are here now.

This response is somewhat MI-consistent. Although the provider seeks to
affirm the client, the selected phrasing might be perceived as somewhat
unempathic or dismissive by the client. It is obvious from the clients utterance that the important thing to him is the impact his smoking has had on
his family.
MI-Consistent:The way you take your role and responsibility as a father so
seriously is really impressive. Iknow you havent been as successful as youd
like with previous smoking cessation, but it is hard to imagine anyone taking
it more seriously than you do.
This provider utterance is MI-consistent because it affirms the positive
qualities and values that likely underlie Marios self-deprecating statements.
These affirmations may help Mario view himself less as a piece of garbage
and more as a flawed human being who is still capable of change.
MI-Consistent: You are really dedicated to being a good father. Tell me
about some other qualities such as your dedication to your family that might
help you quit smoking.
This provider response is MI-consistent because it affirms a strength of the
client. The statement also explicitly encourages the client to identify other
strengths he may not be recognizing at this time.
Difficulty Concentrating
Concentration generally refers to the ability to focus ones attention or thoughts
on a particular object or activity, and not attending to distractions (Lezak,
1995). Difficulty concentrating often interferes with an individuals ability to
learn new information. For example, as youve been reading this book, there
have probably been one or more occasions when your thoughts wandered to
another topic (e.g., I have to remember to mail that letter tomorrow.) or you
noticed something new in your environment (e.g., The sky is getting dark, a
storm must be rolling in.). As you noticed your distraction and directed your
thoughts back to the text, you may have realized you had no idea what you
had read in the past five minutes. Difficulty concentrating can also impair an
individuals ability to respond appropriately and effectively in social situations.
For example, multiple times while writing this book, I(JS) received a call from
my husband. Not wanting to lose my train of thought before getting it down on
paper, Itried to multi-taskto talk to my husband and finish typing my ideas
for this book. Needless to say, my husband noticed (and commented on it!).
There were inappropriately long pauses in my speaking, Isometimes provided
incoherent responses to his queries, and occasionally had to ask him to repeat
what he had just said. Although not unique to depression, individuals who suffer
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from depressive disorders often report difficulty concentrating. Individuals who

experience excessive worry (generalized anxiety disorder), posttraumatic stress
disorder, attention deficit hyperactivity disorder and certain other psychiatric
conditions may also experience difficulty concentrating. Indications that your
client may be experiencing difficulty concentrating are presented in the quick
reference box.
Quick Reference
Indicators of Concentration Difficulties in Clients
Frequent requests for repetition of information or questions
Inability to respond to queries about content previously discussed in the session
The appearance of daydreaming
Losing train of thought
Example: When Mario, the 36-year-old, divorced father of three proceeded with his intake at the smoking cessation clinic, the provider began
to ask him a question about his history of smoking. Mario began telling
the provider about how he started smoking at the age of 16 by stealing his
fathers cigarettes and buying them from a local convenience store that
didnt seem to care about selling to minors. Then Mario paused for a few
moments, got a confused look on his face, and asked, Im sorry, what was
the question?
Proposed Strategy 5:Summarizing

As outlined in chapter 2, the basic skills of MI are open questions, affirmations, reflections, and summaries (OARS). Rosengren (2009) outlines three
different primary purposes that MI-consistent summaries can serve during a
provider-client interaction, including listing important things the client has said
(e.g., change talk), linking something a client has just said to something said
previously, or helping to transition the conversation to a new topic or new MI
process (e.g., transitioning from evoking to planning). It has been our experience
that summaries can also be used as a tool to enable a client who seems to have
difficulty concentrating to better participate in an interaction. For clients who
have difficulty concentrating, listing summaries may not only reinforce previously discussed material, but they may enable the client to grasp content of the
session that was missed due to difficulty concentrating. Linking and transition
summaries may help the client draw conclusions or make connections that he or
she was unable to make during the session because he or she was distracted by
other thoughts.
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Example:MI-Consistent/Inconsistent Summaries
The following examples illustrate how a provider might use summaries to
help a client who has difficulty concentrating participate more fully in an
interaction.
Client Statement:Im sorry. What was the question?
MI-Inconsistent:Mario, you really need to focus on what were doing here.
Iasked you to tell me about your history with smoking.
This statement is MI-inconsistent because the provider not only repeats the
question, but also attempts to shame the client about his lack of concentration. The provider talks down to the client in a paternalistic fashion, which
could spring the expert trap.
MI-Inconsistent:Dont worry about it. Lets just go on to the next question.
Although this provider statement indicates that the provider is sympathetic
to the clients difficulty concentrating, it is not collaborative. The client
requested that the question be repeated and the provider in essence overrules this request and takes full control of the direction of the session.
Somewhat MI-Consistent:Tell me about your history with smoking.
This provider statement is somewhat MI-consistent. The client asked a question and the provider responded. In MI, answering a question is considered
a form of giving information. However, given the circumstances, the providers perfunctory response shows a potential lack of empathic attunement
to the difficulties Mario is having with the interview.
MI-Consistent:I had asked you about your history of smoking and you were
telling me about how you started at the age of 16 with smoking your fathers
cigarettes and purchasing them from a convenience store that didnt check
your ID.
This provider utterance is an MI-consistent summary. It is a collaborative
response to the clients question that is intended to help the client fully
engage in the interaction.
Proposed Strategy 6:Using MI-Consistent Handouts

Although written change plans, decisional balance worksheets, readiness rulers, and informational handouts are considered optional components of an
MI-consistent provider-client interaction, we have found that many clients,
regardless of their ability to concentrate, appreciate receiving these materials.
These materials can help clients recall and refer back to key elements of their
interaction with the provider. For example, several clients who receive motivational interviews from psychology interns through an MI practicum I(JS) supervise at a community residential substance abuse treatment facility report posting
their change plan worksheet beside their beds. They report that they like to be
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reminded daily of their goals and the steps they plan to take in achieving those
goals. The fact that these documents are so meaningful to these clients is very
telling; the motivational interview they receive represents just one hour out of
100 or more hours of treatment they receive. Similarly, the change plan worksheet represents just one of dozens of treatment-related papers they complete
during their six-week stay at the facility. We have also found that these types of
aids can be particularly helpful for clients who have difficulty concentrating and
thus may be less able to recall key elements of the session than typical clients.
Example:MI-Consistent/Inconsistent Handouts
The following examples illustrate the types of MI-consistent handouts
that might be provided to a client to help him or her overcome deficits in
concentration.
MI-Inconsistent
Any materials that judge or label a clients situation, condition, or
circumstances in a way that is inconsistent with how the client labels
his or her own situation, condition, or circumstances (e.g., providing a
handout that describes Signs of Alcoholism to a client who insists that
he may drink a lot but is not an alcoholic.)
Any materials that describe a treatment plan that was created without
the clients collaboration or give advice with the clients permission (e.g.,
handing a client a dietary guidelines handout and telling him or her to
follow it rather than asking if he or she would like the handout, or giving
the client permission to use it or not by saying, You might find this
helpful.).
Somewhat MI-Consistent
Handouts that provide information in an objective, non-labeling fashion
that is consistent with the clients self-perception, but are not requested
by the client or offered to the client with permission to disregard them if
desired.
MI-Consistent
Session/consultation/meeting agendas can be negotiated and presented
in written or verbal form. After the agenda has been negotiated
between a provider and client, placing a written version of the agenda
between the client and provider may help a client who has difficulty
concentrating stay more focused during the interaction. Samples of
written agenda forms can be found in Mason and Butler (2010).
Readiness rulers are used as both an assessment tool and a technique
for eliciting change talk (Rollnick, Miller, & Butler, 2008). These rulers
can be administered verbally or in written form. For clients who have
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difficulty concentrating or might otherwise benefit from having a

record of this exercise, a written form that includes both their rating
and a written description of the reasons for the rating might be used
(Table 6.1).
Decisional balance (Janis & Mann, 1977), which used to be considered
a strategy for evoking change talk in MI (Miller & Rollnick, 2002)and
is now considered a neutral strategy for assisting a client in determining
whether or not they desire to change (Miller & Rollnick, 2013), involves
having a client articulate the reasons to change and the reasons to stay
the same. Decisional balance exercises are often completed in written
form and provide the client with a useful summary of all the factors he
or she considered in deciding to change (or not change). Asample form
for completing a decisional balance is included in Table 6.2. Note that
if you decide to use this technique no form is neededwe often prefer
to draw a large + in the middle of a blank sheet of paper and place
appropriate headings in each quadrant.
During an MI-consistent planning process, the client and provider will
often collaboratively complete a change plan worksheet that is intended
to remind the client of key aspects of his or her change plan. Elements
you may wish to include on a change plan worksheet are the change the
client wants to make, the reasons he or she wants to make the change,
the steps he or she will take or the strategies he or she will use to
change, what supports he or she will need to change (people, treatment
programs, books, etc.), and how he or she will evaluate the plan and
make changes if it is not helping the client achieve desired results (Miller
& Rollnick, 2002). Samples of change plan worksheets are presented in
chapters4 and 7 and Table 6.4.
Lack of Interest in Activities

Lack of interest in activities is another feature of depression that can present
unique clinical challenges. Of particular import in depressive disorders is a lack
of interest in activities that used to be enjoyed or an inability to take pleasure in
activities that were previously enjoyed. Whereas many individuals who are confronted with difficult behavioral changes such as initiating an exercise program,
starting a diet, quitting smoking, or searching for a job may find it difficult to be
interested in or intrinsically motivated to engage in activities that are not immediately rewarding or pleasurable (but do promote progress toward the goal),
most individuals will have no difficulty engaging in activities that are immediately rewarding or pleasurable. For example, I(JS) sometimes found it difficult to
get myself interested in sitting down to work on this book, even though completing the book was a goal of mine and was highly valued. In contrast, Irarely if
ever find it difficult to get myself interested in eating fries from my favorite fast
food restaurant, reading a trashy novel, or getting a massage or pedicure. These
Table 6.1.Sample Readiness Ruler Handout
My Goal Is:
On a scale of 0 to 10, with 0 being not at all important and 10 being very important,
Irate the importance of achieving this goal as (circle one):
01234
5
6
7
8
910
My rating is a
reasons):
and not a lower number for the following reasons (list
1.
2.
3.
4.
5.
On a scale of 0 to 10, with 0 being not at all confident and 10 being very confident,
Irate my confidence in my ability to achieve this goal as (circle one):
01234
5
6
7
8
910
My rating is a
reasons):
1.
2.
3.
4.
5.
and not a lower number for the following reasons (list
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Table 6.2.Sample Decisional Balance Handout

Reasons to Quit Smoking
Reasons to Continue Smoking
This quadrant generally includes

negative consequences the individual
has experienced as a result of the target
behavior (i.e., smoking)
This quadrant generally includes

positive consequences the individual
has experienced as a result of the target
behavior (i.e., smoking)
My doctor is concerned about my

health.
Smoking helps me relax.
My kids hate the smell.
I enjoy smoking.
My workplace is going smoke free.

Cigarettes are expensive.
Reasons not to Quit Smoking
Reasons not to Continue Smoking
This quadrant generally includes negative

consequences the individual anticipates
experiencing as a result of changing the
target behavior (i.e., smoking)
This quadrant generally includes negative

consequences the individual anticipates
experiencing as a result of changing the
target behavior (i.e., smoking)
Now is not a good timeIm under

a lot of stress.
I want to live to see my children get

married.
Ive wanted to quit for over 10years.
With all the money Id save every
year, Icould take my kids to Disney
World.
behaviors are not particularly consistent with any important long-term life
goals, but Ienjoy them. In contrast, individuals who are experiencing a depressive episode may experience difficulty getting interested in or taking pleasure
from activities that normally bring pleasure. For example, an individual who is
experiencing a depressive episode may have no interest in accompanying me to
a fast food restaurant for fries and a milkshake, even though he or she normally
loves fries even more than Ido. Instead he or she might decide, I just dont feel
like it. Indications that your client may be experiencing lack of interest in activities may include reports of decreased engagement in activities, an inability to
generate ideas or options when asked what they would like to do, or direct statements such as I just dont seem to get excited about anything anymore.
Example: As Mario, the 36-year-old, divorced father of three works collaboratively with his provider to develop a plan for tobacco cessation, the
provider suggests that Mario identify ways to reward himself for meeting his
daily smoking goals. After a lengthy pause, the provider explains that many
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individuals find that giving themselves a treat such as 30 minutes playing

video games or using a social networking site, eating a special food treat such
as a miniature candy bar or serving of chips, or getting praise from a loved one
for their successful efforts each day can help them stay on track. Mario hesitates and ponders the providers suggestions and then explains that he cannot
think of anything that he really enjoys right now or would find rewarding.
Although the provider is attempting to be supportive and find activities that
may reinforce the clients successes with smoking cessation, the discussion is
likely to be circular. The more the provider succumbs to the righting reflex and
suggests rewards, the more insistent Mario may become in his arguments that
he simply cannot think of anything. For someone who has depression, you may
have to focus on times when the client was not experiencing depression to identify rewarding activities, things clients like, or strengths.
Proposed Strategy 7:Looking Back

Although clients experiencing depression may not currently be able to identify
activities they find pleasurable, attempting to elicit what things were like and
what activities they enjoyed when they were not feeling depressed can help. Thus,
the MI-consistent strategy of looking back may help (Miller & Rollnick, 2013).
Example:MI-Consistent/Inconsistent Looking Back
The following examples illustrate how a provider might use looking back as
a strategy to address a clients current lack of interest.
Client Statement:I cannot think of anything that Ienjoy right now.
MI-Inconsistent:Mario, we all have something that we like to do. What is
it for you?
This response is MI-inconsistent because the provider actually invalidates
the clients statement and minimizes the struggle he is having. The provider
falls victim to the expert trap and the response is likely to elicit sustain talk
versus generating any potential solutions.
Somewhat MI-Consistent:What did you enjoy before you got divorced?
This response is somewhat MI-consistent. The provider asks an open question to help the client identify things that he used to enjoy. However, the provider asks the question without first reflecting the clients statement. Thus
there is a missed opportunity to express empathy. This failure to acknowledge the clients difficulty before asking the question may also cause the
client to experience this continued questioning as non-collaborative.
MI-Consistent: Mario, I certainly can see that it is a struggle for you to
find things you currently enjoy and that it is frustrating for you. I wonder
if it would be helpful for us to look back to a time before your divorce, when
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you were feeling much better and doing more things. What were some of the
enjoyable things for you at that time?
This provider utterance is MI-consistent. The provider begins by validating the clients situation and feelings about not enjoying things. Next, the
provider acknowledges that there was a prior time when the client was not
depressed and asked the client to look back at that time for ideas.
C L I N I CA L C H A L L EN G E 2:A N X I E T Y, T R AU M A- R EL AT ED,
A N D O B S ES S I V E C O M PU LS I V E D I SO R D ER S
Description
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5), Anxiety disorders include disorders that share features
of excessive fear and anxiety and related behavioral disturbances (pp. 189,
American Psychiatric Association, 2013). A common behavioral disturbance
shared by many anxiety disorders is avoidance. This feature is also shared by
some disorders that were previously classified as anxiety disorders in the DSM
including obsessive-compulsive disorder and posttraumatic stress disorder
(American Psychiatric Association, 2000, 2013). Avoidance refers to efforts by
an individual to avoid people, situations, stimuli, thoughts, or feelings because
they arouse unpleasant emotions, particularly fear or anxiety. For example an
individual who is experiencing a specific phobia of snakes may avoid looking at
pictures of snakes; going to zoos, natural science museums, or pet stores where
snakes might be encountered; and going outside at night or without wearing
boots during the day in case snakes might be encountered.
Avoidance is of concern to those who treat anxiety disorders, because there is
evidence that although avoidance may reduce anxiety in the short term, it actually serves to maintain and even increase anxiety over time (e.g., Clark, 1999).
For example, an individual with a snake phobia who runs back into the house
and locks the door when a neighbor calls to tell him or her that she found a
harmless garden snake in her yard that morning might immediately experience
a decrease in anxiety upon doing so. However, over time he or she might come to
fear and avoid the back patio and backyard entirely, and may eventually refuse to
leave the house unless wearing protective leather boots.
Avoidance presents clinical challenges, because many of the most effective
psychotherapies for disorders such as specific phobia, obsessive-compulsive disorder, and posttraumatic stress disorder include exposure-based interventions
(Doyle & Pollack, 2003). Exposure-based interventions involve having an individual who is avoiding situations, people, stimuli, thoughts, or feelings because
they elicit a strong anxiety or fear reaction to intentionally come into contact
with those situations, people, stimuli, thoughts, or feelings and tolerate the
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intense anxiety or fear (Hofmann & Smits, 2008)Whether you have worked with
individuals who have anxiety, trauma-related, or obsessive-compulsive disorders; watched reality television programs that depict exposure based treatment;
had friends or family members who suffered from such disorders; experienced
an anxiety or related disorder yourself; or have no direct experience with anxiety
or related disorders; you can probably imagine that finding the motivation to
complete exposure-based treatment is a challenge. We admire the courage of the
many individuals we have treated with exposure-based treatments over the years
and have found the use of many MI strategies helpful in assisting these individuals to find the motivation and courage to reclaim their lives through completion
of exposure-based treatment.
Example. Jamal is a 32-year-old man who has been diagnosed with posttraumatic stress disorder subsequent to a single car motor vehicle accident during
which he was seriously injured and the driver of the vehicle was killed. Since
the accident, Jamal has been unable to drive on the freeway, after dark, or
in unfamiliar neighborhoods. He also becomes incredibly upset when he sees
a black sedan (the car involved in the accident was a black sedan) or hears
jazz music (he and the driver were listening to jazz on the radio at the time
of the accident). During their second visit, a social worker provides Jamal
with information about his diagnosis and exposure-based treatment. Jamal
expresses that the symptoms of PTSD have ruined his life and he is willing to
do whatever it takes to get past this. However, shortly after the exposure-based
interventions begin, Jamal states that he is not certain he wants to continue
with treatment and tries to convince the social worker that having PTSD is
really not that bad.
As illustrated in this example, avoidance can interfere with a clients ability to
complete exposure-based treatment, even if he or she does not express any initial
hesitation or concern about the treatment. In our own work, we find that not all
clients express doubt about their ability to tolerate exposure-based treatment. In
fact a significant minority express unrealistic optimism about their ability to tolerate exposure-based treatment without any difficulty. With the help of a caring,
compassionate, and competent professional, there are only a handful of situations that would be considered contraindicated for exposure-based interventions
(e.g., vanMinnen, Harned, Zoellner, & Mills, 2012). Nonetheless, the very
nature of anxiety, trauma-related, and obsessive-compulsive disorders, as well
as exposure-based treatment almost ensures that an expectation of no distress
or avoidance is unrealistic for most clients. Thus we also outline MI-consistent
strategies to help clients set realistic expectations for exposure-based treatment
(see also chapter5).
Avoidance related to anxiety can interfere with effective provision of interventions and services of all types, not simply those that involve exposure-based
treatments (Westra, 2012). Individuals with social anxiety have intense fear
or anxiety about one or more social situations that expose the individual to
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possible evaluation by others. This fear and anxiety stem from a belief they will
act in some way that will be negatively evaluated by others in the feared social
situations. As a result these situations are avoided or endured with intense fear
and anxiety (American Psychiatric Association, 2013). For example, individuals with social anxiety may avoid making phone calls, coming to appointments, speaking up in groups, or engaging actively in one-on-one meetings.
This fear, anxiety, and avoidance may interfere with an individuals ability to
participate fully in almost any situation or setting in which MI might be utilized, from a meeting with a probation officer, to an appointment with a family care provider, to a substance abuse treatment group. In our own clinical
practice of MI and supervision of others MI practices, we have identified MI
strategies that may be useful in working with individuals who avoid treatment
because of social anxiety.
Example. Sanjay is an 18-year-old male who suffers from social anxiety. He
has been referred to the counselor at his school to discuss decreasing attendance and performance. Sanjays teachers report that he often looks at his
desk or fiddles with his pen, never raises his hand to participate in class discussions, and often seems unprepared when called upon to answer a question
or present information to the class. As the counselor talks to Sanjay about his
problems at school she discovers that several of his classes require presentations this year and that his political science instructor, a former law professor, often calls on students randomly and expects them to know the answer.
Sanjay explains that his heart races whenever he thinks about the presentations and political science class and he just knows hes going to mess up in
front of the class and all of the kids will think hes stupid.
Proposed Strategy 1:Empathic Listening

We know from our work with community providers who do not specialize in
mental health (and even sometimes those who do) that lack of engagement due
to social anxiety is often misattributed to lack of motivation or weakness. As you
read these descriptions, you might have been thinking, Who hasnt felt their
heart race when they stand up to speak before a crowd of people? or Who hasnt
shuddered a bit when they saw a particularly fearsome looking snake or spider?
As with depression, it is important to note that although everyone experiences
fear or anxiety from time to time, the experiences are more intense and impairing in the context of an anxiety disorder (APA, 2013). Thus, it is very important
to listen empathically and attempt to understand the clients experience of anxiety rather than assuming that your personal experience with anxiety makes you
an expert on the clients experience. This is true even if you have suffered from
the same disorder the client is experiencing (see c hapter8 for additional information about the unique challenges that arise when working with clients who
are similar to you).
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Example:MI-Consistent/Inconsistent Empathic Listening

The following examples illustrate how to use empathic listening to understand the role anxiety may play in a clients lack of participation in an
intervention:
Client Statement:Im going to say something stupid and the other kids are
going to laugh at me.
MI-Inconsistent:Everyone gets nervous sometimes Sanjay. You just need to
have faith in yourself and speak out confidently.
Although the provider seems to be trying to express warmth and compassion to the client, this provider utterance is nonetheless MI-inconsistent.
Instead of demonstrating empathy by reflecting Sanjays concerns, the
provider instead provides information as an attempt to dismiss Sanjays
concerns. The provider then goes on to tell Sanjay what to do, which is not
collaborative and does not support Sanjays autonomy.
Somewhat MI-Consistent:What do you think might make you feel less nervous about speaking up in class?
This response is somewhat MI-consistent. The provider asks an open question that invites Sanjay to share his perspectives. However, this question is
asked before the provider has elicited enough information from Sanjay to
really understand what his experience of anxiety is like, and what his motivations to implement strategies to reduce anxiety might be.
MI-Consistent:You are really worried that the other kids might think poorly
of you if you speak up in class.
This provider utterance is MI-consistent because the provider empathically
reflects the clients feelings and concerns without trying to minimize them
or force him to adopt a new perspective.
MI-Consistent: So if you felt more confident that the other kids wouldnt
laugh at you, youd be more willing to participate in class.
This provider utterance is also MI-consistent and is also an empathic reflection. This reflection is more complex than the previous example as the
provider reframes the clients concerns as a possible intervention target.
Aprovider might choose this type of reflection to help the client begin to
consider that change is possible.
Proposed Strategy 2:Assessment Feedback

In our work with individuals with anxiety disorders, obsessive-compulsive
disorders, and trauma-related disorders, we have found that many clients benefit from provision of MI-consistent feedback from their diagnostic assessment
(e.g., Miller, Zweben, DiClemente, & Rychtarik, 1992). An example comes from
a recent clinical trial that included an MI-based intervention as a preparatory
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intervention for individuals who enrolled in a clinical trial for treatment of

co-occurring alcohol use disorders and posttraumatic stress disorder (Coffey
etal., 2013). In this study, we found that the first participants who enrolled in the
study had difficulty articulating the potential benefits of receiving treatment for
posttraumatic stress disorder because they did not realize that the constellation
of distressing and life-interfering symptoms they were experiencing could all be
traced to their diagnosis of posttraumatic stress disorder. However, once provided with objective information about the diagnosis, including feedback from
their diagnostic evaluation, participants could readily articulate:(1)the ways in
which the symptoms, distress, and impairment associated with posttraumatic
stress disorder had negatively impacted their lives, and (2) the way their lives
would be better, richer, and fuller if they were successful in treatment and no
longer experienced the symptoms, distress, and impairment associated with the
diagnosis.
Example:MI-Consistent/Inconsistent Assessment Feedback
The following examples with Jamal, the man described earlier who developed posttraumatic stress disorder as a result of a motor vehicle accident,
illustrate how a provider might use assessment feedback to help a client with
an anxiety, trauma-related, or obsessive compulsive disorder develop sufficient motivation to participate in treatment and reduce their symptoms.
Client Statement:My life has been ruined ever since the car accident.
MI-Inconsistent:If you want to regain your life, Irecommend you participate in a treatment called exposure therapy.
This response is MI-inconsistent because the provider gives advice without
permission, which reduces collaboration and may also diminish the clients
sense of autonomy. The provider also fails to demonstrate empathy with
Jamals obvious angst.
Somewhat MI-Consistent:You have a disorder called PTSD and that is why
youve been struggling so much since the accident. You can do a treatment
called exposure therapy that will help you get past it.
This response is somewhat MI-consistent. The provider offers Jamal objective information about his condition. However, the provider does not ask
permission before giving the information or elicit the clients response to
the information. The provider also jumps to planning (offering a treatment
approach) without eliciting Jamals motivation for treatment.
MI-Consistent:Jamal, would it be okay with you if Ishared some feedback
from your assessment that might help you better understand why things have
been so difficult for you since the car accident?
This provider utterance is MI-consistent, because the provider asks permission to give information, which supports the clients autonomy, and also
demonstrates both sympathy and empathy for the difficulty the client has
experienced as a result of the car accident that took the life of his friend.
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Table 6.3.Example of Objective Written Feedback from a PTSD Assessment

Posttraumatic Stress Disorder Assessment Results
TRAUMATIC EVENTS IN YOUR LIFE
YOUR TRAUMA SYMPTOMS

Posttraumatic Stress Disorder (PTSD) Diagnosis yes
no
Avoidance symptoms
Re-experiencing symptom
Hyperarousal symptoms
Overall trauma symptom severity: mildmoderateseverevery severe
Table 6.3 provides an example of what MI-consistent written feedback from

a PTSD assessment might look like. This feedback is most helpful when presented in the context of verbal or written interpretive information that will
help clients make the most of the information (e.g., Miller etal., 1992).
Proposed Strategy 3:Evocation

For clients who present with anxiety, trauma-related, or obsessive-compulsive
disorders for which an exposure-based treatment is recommended, using
MI-consistent evocative questions to help them articulate their own reasons for
change may be essential to helping them foster the motivation and strength to
overcome their avoidance and pursue treatment (Westra, 2012). Evocative questions can most easily be accomplished after clients have been provided with
assessment feedback or other information that gives them a clear understanding
of how the symptoms they have been experiencing are linked to their diagnosis.
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Example:MI-Consistent/Inconsistent Evocation
The following examples illustrate how a provider might use evocation
to help a client develop sufficient motivation to overcome avoidance and
engage in treatment:
Client Statement:My life has been ruined ever since the car accident.
MI-Inconsistent:Well, Ihave good news Jamal. Ican offer you a treatment
that is very effective for helping people move past traumatic events like car
accidents.
This provider utterance is MI-inconsistent, because the provider does not
evoke the clients desire, ability, reasons, need, or commitment for change.
Instead the provider assumes that because the client reports that his life is
ruined that his motivation is sufficient and jumps directly to planning. The
planning is MI-inconsistent because it is non-collaborative; the provider
is prescribing a treatment rather than inviting the client to participate in
determining what treatment will be best for him.
Somewhat MI-Consistent:Would you like to talk about treatment options
that might help you regain your life?
This provider utterance is somewhat MI-consistent. The provider asks the
client permission to discuss treatment options. By asking permission and
using the word options, the provider enhances the sense of collaboration
and client autonomy. However, the provider does not seek to elicit the clients desire, ability, reasons, need, or commitment for change before moving to treatment planning. The provider also uses a closed question, which
invites only a brief response from the client.
MI-Consistent:So this has been really hard on you. Tell me a little about
what has been different or bad about your life since the car accident.
This provider utterance is MI-consistent, because it begins with an
empathic reflection of the clients comment about his life being ruined.
The provider then invites the client to explain in more detail exactly
how the car accident has negatively impacted him. The more change
talk statements the provider elicits, the more likely the client will decide
he is ready to commit to treatment (Amrhein, Miller, Yahne, Palmer, &
Fulcher, 2003).
Proposed Strategy 4:Offering Choices

As outlined in chapter2, a component of the foundational spirit of MI is acceptance, which includes autonomy supportthat is, provider support of the clients right to choose the best course of action for him- or herself (see also Miller
& Rollnick, 2013). Thus in discussing treatment, an MI-consistent provider
should strive to offer objective information about options available to the client,
including the potential pros and cons of each option. The provider should then
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collaborate with the client in deciding which course of action is best, keeping in
mind that the client is the final arbiter of what he or she will or will not do. As
I(JS) advise the medical students each year during a brief lecture on practices
and principles of MI, no matter what the treatment outcome literature and practice guidelines say, a treatment that the client will not adhere to is probably not
the best treatment for that client.
In the case of anxiety, trauma-related, and obsessive-compulsive disorders, clients have many treatment options ranging from no treatment, to medications, to
cognitive or behavioral psychotherapies, to supportive psychotherapy. Providers
should be knowledgeable about treatment outcome data and practice guidelines to offer clients accurate and objective information about the implications
of selecting a particular intervention, completing between-session assignments,
and/or dropping out of treatment before it is completed. Keep in mind that while
it is MI-consistent for the provider to share his or her professional opinion about
the best intervention option for a client (e.g., Although what you decide is ultimately up to you, my professional opinion is that cognitive behavioral therapy
would be a much better option for you than medication.), it is MI-inconsistent
for the provider to impose it on the client (e.g., Cognitive behavioral therapy is
really the only option for you.).
Example:MI-Consistent/Inconsistent Offering Choices
The following examples with Sanjay, the 18-year old with social anxiety,
illustrate how a provider might offer choices to a client in an MI-consistent
fashion.
Client Statement:I dont see why Ihave to graduate high school. My father
didnt graduate and he makes a lot of money in construction.
MI-Inconsistent:Things are different now, Sanjay. It is a lot harder to make
a decent living without a diploma than it used to be.
This statement is MI-inconsistent because instead of empathically acknowledging the clients perspective, and perhaps inviting another perspective,
the provider seeks to directly counter the clients perspective and impose
the providers perspective.
Somewhat MI-Consistent: Dropping out of high school is certainly an
option.
This statement is somewhat MI-consistent. The provider supports Sanjays
autonomy by acknowledging that dropping out of high school is an option.
However, the provider does not present other options that might help Sanjay
move in his preferred direction. Although Sanjay is expressing a desire to
drop out, the desire seems to be driven largely if not entirely by a belief that
dropping out is the only way to reduce his anxiety. As Miller and Rollnick
(2013) note, there may be occasions when a provider uses MI to help a client consider goals in the clients best interest, even when a client doesnt
initially endorse those goals.
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MI-Consistent:This has obviously become unbearable for you, Sanjay, and

you feel like you need to do something. You have a lot of options in how to
deal with this, and dropping out of school is certainly one of them. As a school
counselor, my job is to help you select the solution that is best for you all things
considered. Ihave some ideas of things that you may or may not think will be
helpful to you, such as working with a counselor like me either alone or with
your parents to learn skills and strategies to attend class without feeling anxious, talking to your doctor about medications that might help you manage
your anxiety, scheduling meetings to talk to your teachers about the problems
youve been having and asking for their help, talking to other students who
used to have the same feelings you have about how they got past it. Iwill tell
you my thoughts about the pros and cons of each of these options, but first
Id like to hear your thoughts about these ideas and whether you maybe have
some others we should put on the list for consideration.
This provider utterance is MI-consistent, because it begins with an empathic
reflection and then supports the clients autonomy to choose his own solution for the problem. It is further MI-consistent because rather than immediately telling the client what she thinks is best solution is, the provider first
lists available options and seeks his perspective on them.
Proposed Strategy 5:Emphasizing Control

Many providers who treat anxiety, trauma-related, and obsessive compulsive
disorders recognize that avoidance is a symptom of the clients disorder and
thus feel compelled to push clients to work through and overcome it, doing
so in a non-collaborative fashion that does not support client autonomy is
MI-inconsistent. Although it is counterintuitive for many providers, we have
found that emphasizing control when clients are having the most difficulty
engaging in treatment is a very useful strategy for helping clients overcome
avoidance. In our experience, clients who are particularly uncertain about
their ability to tolerate treatment may begin almost every in-session exposure
practice with a statement of uncertainty and reluctance about continuing with
treatment. This is followed, of course, by a statement from the provider supporting the clients autonomy and right to choose what they do or do not do in
a particular session.
Example:MI-Consistent/Inconsistent Emphasizing Control
The following example illustrates how a provider might use emphasizing
control to address the clinical challenge of avoidance with Jamal, the man
who is suffering from motor vehicle accidentrelated PTSD.
Client Statement:Im not sure Ican handle the exposure today.
MI-Inconsistent:It is important for you to go on, Jamal.
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This statement is MI-inconsistent because the provider does not acknowledge the clients concerns or support his autonomy, and instead directly
confronts his reluctance to participate in treatment.
Somewhat MI-Consistent:Why cant you handle it, Jamal?
This question is somewhat MI-consistent. It is an open question and thus
elicits the clients perspective. However, it is a question that elicits sustain
talk, and thus will encourage the client to talk about why he cant move
toward his own treatment goals, rather than why he can. Additionally, the
specific wording of the question (Why cant you... ) may be perceived as
confrontational by the client. It implies that the provider thinks the client
should be able to handle it.
MI-Consistent: Jamal, you are in control here. It is entirely up to you
whether you do the exposure today. As weve discussed before, you know that
my recommendation is that you do it, because the more you confront what
you fear, the less you will fear it. But ultimately it is up to you whether to do
the practice today.
This provider utterance is MI-consistent because although the provider
reminds the client of previously discussed information about the importance of completing exposure practices, the provider also repeatedly supports the clients autonomy and right to decide not to do the practice.

As outlined further in the discussion of Proposed Strategy 7:Envisioning, many
clients may underestimate the extent to which avoidance might interfere with
their ability to successfully complete treatment for an anxiety, trauma-related,
or obsessive compulsive disorder. Helping a client prepare for the possibility that
avoidance might interfere with his or her ability to participate in a desired treatment is another MI-consistent strategy for addressing this clinical challenge. As
described in chapter3, during MI-consistent planning the provider works collaboratively with the client to devise strategies to address avoidance when and
if it occurs. The provider should also revisit and update this plan as needed to
ensure that the client is successful in achieving his or her goal of overcoming
avoidance in order to successfully complete treatment.
The following examples illustrate how a provider might use planning to
help a client, such as Jamal, prepare to successfully overcome treatment
avoidance.
Client Statement:Im willing to give this treatment a try, but Im not really
sure about it.
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MI-Inconsistent: Jamal, your reluctance is probably based on avoidance,

which is a symptom of posttraumatic stress disorder. You need to come to sessions regularly even if you dont feel like it. Will you do that?
Although the provider begins with information provision about avoidance,
which is not MI-inconsistent, the provider goes on to tell the client what to
do about the avoidance, which is MI-inconsistent. Telling the client what
to do is not collaborative, and may diminish the clients sense of autonomy.
Somewhat MI-Consistent:Jamal, Iwould recommend that you use breathing exercises and positive self-statements whenever you feel uncertain about
treatment. But that may or may not be the best strategy for you.
The provider offers advice with permission to disregard, which is
MI-consistent and promotes some sense of autonomy and collaboration.
However, the response overall is only somewhat MI-consistent because the
provider offers this advice without first eliciting Jamals thoughts about
what might help him participate in treatment. Thus the collaboration is
lukewarm.
MI-Consistent:Jamal, if Imay provide some information, your reluctance
is probably based on avoidance, which is a symptom of posttraumatic stress
disorder. Many clients who really want to overcome posttraumatic stress disorder, but are uncertain about treatment find it beneficial to discuss ahead
of time what they will do if they begin finding it difficult to continue to treatment. Would it be okay if we did that now? [Provider waits for affirmative
response]. Lets start off by discussing what types of things might make you
decide that treatment is too difficult or you dont want to continue.
This provider utterance is MI-consistent, because it begins with information provision and then segues into an invitation to the client to participate
collaboratively in devising a strategy to address avoidance.
One way we have framed these plans in our own work is Making a Plan
for Successful Treatment. Change plan worksheets, such as the one in
Table 6.4, are commonly used in MI (e.g., Miller & Rollnick, 2002).
Proposed Strategy 7:Envisioning

We have found that helping clients realistically envision what treatment might be
like is often a useful strategy for clients who have unrealistic expectations (see also
chapter5). Given that the reality of treatment for most clients is that it is beneficial
and manageable, but requires emotionally intense and perhaps time-consuming
hard work, this strategy will often result in clients voicing a small amount of sustain talk. An example of the type of utterance that might result from use of envisioning with a client who has unrealistic expectations of treatment might be, I
guess maybe the exposure practices might be hard, but if Ithink about how much
it will help me, it will keep me going. Although eliciting sustain talk is in most
Table 6.4.Sample Plan for Successful Treatment

Making a Plan for Successful Treatment-Example
The most important reasons why Iwant to successfully complete treatment are:
1. So Ican get my life back.
2. So Ican drive without fear.
3. So Istop thinking about the accident all the time.
4. So Idont teach my kids to be afraid of driving.
To successfully complete treatment Imust:*
1. Attend treatment regularly.
2. Complete in-session practices to the best of my ability.
3. Complete all homework assignments to the best of my ability.
Some things that could interfere with successful completion of treatment are:
1. My tempersometimes when Iget scared, Iget angry and just say forget
about it.
2. My prioritiesI may decide that Ineed to work or do other things besides
completing treatment.
3. Something will happen with my family that makes me feel like Ineed to stop
treatment.
4. Imay talk myself out of it.
The ways other people can help me are:
1. My family can encourage me to keep going.
2. My therapist can encourage me and remind me that the end is in sight.
3. My therapist can call me if Imiss an appointment and encourage me to
reschedule.
What Iwill do if Iam not sticking with treatment the way Ihad hoped or am
considering dropping out:
1. Be honest with myself, and not blame other people for my part in this difficulty.
2. Remind myself of how bad things were and how many times Ive tricked myself
into avoiding things because Im anxious.
3. Remind myself that Iam strong and Ican do this!
4. Pray for strength, courage, patience, wisdomwhatever Ineed to make it
through the difficult time.
5. Ask family, friends, and others for support and a pep talk.
6. Remember all the success Ihave had in treatment.
* Many ideas for what to list in this section may be offered by the provider as the
provider will be more knowledgeable about the components of the treatment the
client has selected.
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cases an MI-inconsistent strategy, eliciting a small amount of sustain talk is sometimes helpful in preparing clients who do not have a realistic perspective on the
potential difficulties of exposure-based treatment. Nonetheless, it is a strategy we
recommend be used sparingly and only when clinical judgment suggests it is warranted. We personally use this strategy only when a client expresses a strong belief
that an exposure-based treatment for anxiety will be easy and he cannot imagine
encountering any difficulties when completing it. For example, if a provider says,
This exposure-based treatment for anxiety will involve repeatedly coming into
contact with those things that make you most anxious and staying in the situation for a predetermined amount of time, such as 30 minutes, or until your anxiety diminished by 50%. What questions or concerns do you have? If the client
says, I dont have any concerns, it sounds straightforward. Lets get started, the
provider may wish to help the client better envision what treatment will really be
like and gain a more realistic perspective on the treatment. This will help ensure
that the client is not disappointed, or does not feel like a failure if he or she does
experience difficulty with treatment at some later point.
Example:MI-Consistent/Inconsistent Envisioning
The following examples illustrate this likely controversial, but potentially
very useful strategy as a provider and client discuss treatment for posttraumatic stress disorder.
Client Statement:I dont have any concerns. PTSD has ruined my life and
Ill do anything it takes to get past it.
MI-Inconsistent: It doesnt sound like you are being very honest with
yourself.
This provider utterance is MI-inconsistent because the provider directly
confronts the clients optimism, which is not collaborative and does not
support the clients autonomy.
Somewhat MI-Consistent:Tell me one concern that you might have about
PTSD treatment.
This provider utterance is somewhat MI-consistent. It is an open question
(tell me statements are considered open questions in MI) and thus invites
a lengthy answer from the client. However, given the context (the client has
just stated I dont have any concerns), it is likely to elicit discord. The client may feel that the provider is not listeningor worse yet, may feel confronted by the provider.
MI-Consistent:So you are very confident and ready to go. Many people who
go through this treatment find that it is more difficult or more intense than
they expected. What do you think might happen in treatment that might
make you feel less certain about wanting to continue with it?
Although the provider is likely to elicit a small amount of sustain talk by
asking the client to envision what might be difficult in treatment, which as
stated is not strictly MI-consistent, the provider does so in an MI-consistent
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fashion. The provider first empathically reflects the clients optimism and
then objectively provides information that does not directly counter what
the client has said, but perhaps gives him food for thought. Finally, the provider asks an open question seeking to elicit the clients perspective on what
might happen that might be difficult in treatment. This then allows the provider to work with the client to plan for and successfully overcome these
barriers as discussed in Proposed Strategy 6.
C L I N I CA L C H A L L EN G E 3:PSYC H OT I C SY M P TO M S
Description
Psychosis refers to a loss of contact with reality that usually includes false beliefs
about what is taking place or who one is (delusions) or seeing, hearing, smelling,
tasting, or feeling things that arent there (hallucinations). In addition to hallucinations and delusions, other symptoms of psychosis include disorganized thoughts,
speech, and behavior. Psychosis can be caused by a number of medical problems,
such as alcohol and drug use or withdrawal, and diseases or tumors that affect
the brain, as well as psychiatric disorders such as schizophrenia, bipolar disorder,
severe depression, and some personality disorders. Although treatment depends
on the cause of the psychosis, it typically includes an antipsychotic medication
(Cohen, 2010). MI shows promise for helping individuals with psychotic disorders,
particularly schizophrenia, better adhere to necessary medications (Drymalski
& Campbell, 2009) and make other positive changes in their lives, such as
decreased problematic alcohol consumption (Graeber, Moyers, Griffith, Guajardo,
& Tonigan, 2003) and increased contact with smoking cessation professionals
(Steinberg, Ziedonis, Krejci, & Brandon, 2004). Nonetheless, psychotic symptoms
and disorders present unique challenges to the implementation of MI (e.g., Rusch
& Corrigan, 2002). More than once community providers have tried to stump us
by role playing a client with psychotic symptoms during a trainingevent.
Example:Roger is a 63-year-old man who has been diagnosed with schizophrenia and is being cared for in a board and care home. Rogers adherence to
his antipsychotic medications has varied over the past 40years. During periods of lower adherence, he often spends months or years living on the street
until his family tracks him down and he is admitted to an inpatient psychiatric facility for stabilization. Recently, Rogers physical health has worsened,
and the staff at the board and care home believe Roger will need to be cared for
in a skilled nursing facility. For example, due to his medical condition Roger
often falls. Because of his large stature, Regina, the weekend house manager
at the board and care facility (a petite woman), has difficulty assisting Roger
when this occurs. This difficulty is compounded by the fact that Roger is often
shouting incoherently after a fall and has difficulty responding to Reginas
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instructions. Roger seems to have little insight into his physical health concerns, and has dismissed staff attempts to initiate discussions with him about
their concerns. Almost as soon as these discussions are initiated, Roger insists
that he is in peak physical condition because the CIA has injected him with
experimental drugs to enhance his performance.
How would you respond to Roger? Would you argue with Roger about the
unreality of his beliefs? Would you recommend that the psychiatrist increase
his medications so he is too sedated to leave his bed? Would you go to the court
to have Roger committed to a nursing home for his own safety? Would you quit
your job at the board and care home and find a less stressful position? The text
will outline several MI-consistent strategies that may be useful when working
with clients who have delusions, hallucinations, or disorganized thoughts and
behaviors. However, it is important to note that adaptations to commonly used
MI strategies are often necessary when working with individuals who suffer
from psychotic symptoms or disorders. Carey, Leontieva, Dimmock, Maisto, and
Batki (2007) have recommended adapting motivational enhancement protocols
for individuals with schizophrenia to include more frequent, briefer sessions.
Carey and colleagues describe the potential benefits of this adaptation for clients
with schizophrenia as:(1)decreased demands on attention; (2)increased opportunities for clients to learn how to respond to an MI-style intervention; (3)greater
repetition of and elaboration of content; (4)better integration of real-life events
into discussions; and (5)attenuated impact of a bad day (e.g., a day on which
symptoms or stressors are much worse) on overall treatment outcome. Martino,
Carroll, Kostas, Perkins, and Rounsaville (2002) recommend several adaptations of MI for individuals with psychotic disorders to accommodate disordered
thinking and cognitive impairments, such as simplifying open-ended questions
(e.g., avoiding compound questions), emphasizing the provider role in guiding
the conversation to promote logical organization and reality testing, reducing
reflections focused on disturbing life experiences, and increasing emphasis on
affirmations of the client. It is important to note that many of these strategies as
well as those presented here, are less appropriate or less effective for clients who
are highly disorganized or agitated.

It has been our experience that some clients who have been involved in the medical, substance abuse treatment, or criminal justice systems for a long period of
time experience initial surprise or uncertainty when working with a provider who
is using an MI-consistent approach. For example, they may provide very short
answers in response to open questions or sit in silence after a provider offers a
reflective listening statement. Client uncertainty is not surprising given how dissimilar MI is from many of the directive approaches most commonly employed
in those settings and from interpersonal interactions in general (Amrhein etal.,
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2003). Despite this initial uncertainty, we have found that most of these clients
readily adapt to MI spirit and techniques, and very actively and fully participate
in the interaction within a few minutes. As Martino and colleagues (2002) note,
individuals with disordered or disorganized thinking may have more difficulty
adapting readily to an MI style. Thus, they recommend providing the client with
an informative overview prior to an MI-style interaction. During this overview
the client is informed not only of the purpose of the interaction, but also the roles
that the client and provider will have during the interaction.
The following examples illustrate how giving information can be used to
orient clients with cognitive impairments to an MI-style interaction.
Client Statement:How long is this going to take? Ihavent had a cigarette
in hours.
MI-Inconsistent:Roger, you can have a cigarette after were done. The staff
has decided that we can no longer care for you here. We are going to recommend to your case worker that you be placed in a skilled nursing facility. Do
you have any questions?
This provider utterance is MI-inconsistent because the provider does not
attempt to collaborate with Roger. Instead the provider dismisses Rogers
request for information about the length of the appointment and his obvious desire for a smoke break. Then the provider assumes the expert role and
tells Roger that a decision has been made about his care. The final question
is almost MI-consistent, in that the provider seeks to get Rogers perspective
on what he has just been told, but it is phrased as a closed question, which
invites Roger to provide only a brief answer (e.g., yes or no) rather than
a more lengthy response.
Somewhat MI-Consistent:This will take about 15 minutes Roger.
This provider response is somewhat MI-consistent in that the provider
answers the clients question in an objective fashion. However, the provider
does not ask the clients permission to continue the interaction or provide
any information about the purpose of the interaction and thus does not
support the clients autonomy or set the stage for the client to collaborate in
the interaction.
MI-Consistent: I know you really want a cigarette right now, and at the
same time Id really like about 15 minutes of your time to discuss something
important. Would that be okay? [Waits for client response]. Roger, Id like
to talk to you a little bit about the good experiences and not-so-good experiences youve had with us over the last few months and what the best options
for housing might be for you. Im really interested in learning about what you
think and feel about your housing, so although Imay ask you a few questions
here and there, Im really just interested in hearing what you have to say. Tell
me what you like about living in this house, Roger.
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This provider utterance is MI-consistent because it begins with a reflection

of Rogers desire for a cigarette and an answer to his question. This demonstrates empathy and also establishes a collaborative atmosphere. The provider asks Rogers permission to continue the interaction, which supports
Rogers autonomy and further promotes a collaborative atmosphere. The
provider then offers Roger information to help orient Roger to an MI-style
interaction during which the pros and cons of his current living arrangement will be reviewed. This should prepare Roger to collaborate more
actively in the discussion. It is important to note that using an MI style
does not guarantee that Roger will agree with the staffs determination that
they are no longer able to provide adequate, safe care for him and that it is
time for him to move to another type of facility. Thus the staff at the board
and care home may ultimately have to go against Rogers wishes to stay at
their facility. Nonetheless, engaging Roger in a discussion that invites his
perspective and allows him to control those aspects of the situation that are
under his control (e.g., the location of the facility to which he transfers) support and emphasize the autonomy that Roger does have.
Proposed Strategy 2:Asking Permission

Asking permission before giving information or advice is an MI-consistent strategy to increase the sense of collaboration and support of client autonomy during
an interaction (Moyers, Martin, Manuel, Miller, & Ernst, 2010). Asking permission can also help add additional structure to an interaction when clients have
difficulty keeping their own thoughts or speech organized. This approach is not
uncommon in standard implementation of MI and MI hybrid interventions such
as motivational enhancement (Miller etal., 1992)or motivational interviewing
assessment (Martino etal., 2006). For example, in an MI session, the transition
from eliciting to planning might be marked by a provider utterance such as If
it is okay with you, Id like to shift gears and begin developing a plan for helping your reach your goals. However, more frequent use of such utterances than
would be typical may be beneficial for clients who have difficulty sustaining as
structured, focused dialogue on a particular topic.
Example:MI-Consistent/Inconsistent Asking Permission
The following examples illustrate how a provider might use giving information to help a client maintain focus throughout the session:
Client Statement: Ive been taking my medications every day. Theres no
problem with that.
MI-Inconsistent: I know you are taking them right now, Roger, but it is
important for us to talk about the times you havent been taking them. Every
time you stop taking them you decompensate.
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Although the provider acknowledges the clients recent success with

medication adherence, which is MI-consistent, the provider quickly dismisses this success and shifts the focus in a non-collaborative fashion
to times the client has been less successful, which is MI-inconsistent.
The provider then offers information about medication adherence not
to inform the client, but to confront him about the problems his past
behavior has caused.
Somewhat MI-Consistent:If its okay with you, Id like for us to talk about
the times when you havent been taking your medication.
This statement is somewhat MI-consistent because the provider seeks the
clients permission to discuss medication adherence. However, given that
the client has just stated that he has been compliant with his medication,
the specific wording of this utterance is likely to be perceived by the client as non-collaborative. The provider also misses an excellent opportunity to affirm a client who is obviously seeking positive feedback from
the provider.
MI-Consistent: Youve been quite successful with your medications for
the last several months, Roger. Thats really impressive. If its okay with you
Id like to spend at least a few minutes talking about what has sometimes
made it hard to be successful in the past. Many clients find their symptoms worsen and they lose a lot of progress when they stop taking their
medications.
This provider utterance is MI-consistent because it begins with an affirmation of the clients success. The provider then asks permission to change
the topic to possible reasons for past adherence, but is careful to do so in a
way that does not diminish the prior affirmation of the clients success. The
provider also offers information about the importance of discussing medication adherence, but does so in the third person, which makes it less likely
to arouse defensiveness (Rollnick etal., 2008).
Proposed Strategy 3:Summarizing

As noted in chapter2, summaries are an opportunity for the provider to pull
together and synthesize several of statements the client has made. When used in
MI, summaries are often selective. That is, the provider may choose to include
key points the client has made, such as change talk statements, while omitting
other things the client has said that are less relevant to the focus of the interaction. Martino etal. (2002) suggest that summaries can be used to provide logical
organization to client statements. Thus, with clients who may have disorganized
or tangential thinking, a careful summary can be used to organize a clients
thoughts for him or her. Not surprisingly, reflecting or summarizing is much
more challenging for providers who work with clients suffering from psychotic
disorders (Martino etal., 2002), and thus may be difficult for those who are new
to MI to implement effectively.
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Example:MI-Consistent/Inconsistent Summarizing
The following examples illustrate how a provider might use summarizing to
help a client organize his or her thoughts in a meaningful way.
Client Statement: Ive been taking my medications every day. Theres no
problem with that. My case worker just wants me to go to the nursing home
because she works for them. Ithink shes been poisoning me. Thats probably
why Im falling. The drugs the CIA gives me have been helping. Ithink they
must be an antidote. Can Ihave a smoke break? Iget really nervous when
Icant smoke. Ithink the CIA agent is coming back tomorrow. Can you call
my case worker? Iwant to see my sister.
MI-Inconsistent:Roger, you know the CIA isnt giving you any medications.
This statement is not a summary and is MI-inconsistent because the provider directly confronts the clients delusional thinking. Although the provider is accurate, the manner in which he addresses the clients delusional
thinking is not collaborative and diminishes his sense of autonomy.
Somewhat MI-consistent:So you think shes been poisoning you and that
she works for them.
This statement is somewhat MI-consistent because the provider summarizes a portion of what the client has said. However, the material summarized is unlikely to move the client toward positive change. Instead, the
summary is likely to get the client to expound upon his delusional beliefs.
MI-Consistent:Youve been quite successful with your medications for the
last several months, Roger. It seems like it is important to you to take care
of yourself. Im hearing that the falls are concerning to you, but you are less
convinced that the nursing home is the solution. It sounds like the case worker
has talked to you a bit about why the staff has recommended that for you.
Would it be okay if Ishared a little bit more about the types of benefits we
thought a nursing home might have for you?
This provider utterance is MI-consistent because the provider selectively
reflects statements the client made that support positive, healthy changes.
The provider reflects on the clients medication adherence and guesses that
this might reflect an underlying desire he has to take care of his health. The
provider also reflects the clients brief mention about the falls as a potential
concern. Finally, the provider asks the clients permission to share additional
information about the staffs recommendation. This supports client autonomy and sets the tone for a collaborative discussion about the nursing home.
Proposed Strategy 4:Reflective Listening

In our work training providers who work with individuals who have delusional thinking, one issue that appears particularly challenging is how to stay
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MI-consistent without colluding with the delusionsthat is, without providing additional evidence to support the delusional belief (Nelson, 2005). During
training role plays, when the client makes a delusional statement such as:The
house manager stole my sweater! we find that providers generally respond in
one of two ways:(1)they calmly, but directly confront the client statement:No,
she didnt. No one is stealing from you. in an effort to help bring the client
back into contact with reality; or (2)they reflect the delusional content as though
it were reality-based: The house manager stole your sweater. The first statement avoids supporting a delusional belief, but is likely to increase discord in
the provider-client interaction. Although more MI-consistent, the second statement may serve to reinforce the clients inaccurate paranoid beliefs about the
house manager and encourage the client to continue talking about them. Instead
of direct confrontation or collusion, we recommend that providers strategically
reflect whatever aspect of the client statement or interaction is reality based. In
some cases, the emotion that seems to underlie the clients statements (e.g., fear,
anger) or the process unfolding between the client and provider (e.g., frustration,
misunderstanding) may be the only reality-based material available. An example
would be:You sometimes feel unsure of who you can trust.
Example:MI-Consistent/Inconsistent Reflective Listening
The following examples illustrate how a provider might use reflecting to
emphasize reality-based statements by a client who has disorganized or
delusional thinking.
Client Statement:My case worker just wants me to go to the nursing home
because she works for them. Ithink shes been poisoning me.
MI-Inconsistent:Roger, you know the case worker is not poisoning you.
This statement is not a reflection and is MI-inconsistent. Although the provider is accurate, her direct confrontation of the clients delusional thinking
is not collaborative and diminishes his sense of autonomy.
Somewhat MI-Consistent:Roger that must be very frightening to have the
case worker out to get you.
This statement is a reflection and technically is MI-consistent. However,
because it is a reflection of a delusional belief, it does not help move the client in a direction of positive change. Instead, it may serve to more deeply
entrench the clients delusional beliefs, as a person of authority has agreed
with them (Nelson, 2005).
MI-Consistent:Youre not convinced that a nursing home is the right placement for you, so you question the staffs motives for recommending one.
This provider utterance is MI-consistent because the provider reflects the
clients disagreement about the appropriateness of a nursing home and
his difficulty accepting the staffs recommendation given that he doesnt
agree with their appraisal of his physical condition. The statement does
not directly confront the delusional belief, nor does it in any way support
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the clients erroneous belief that he is being poisoned or that the case
worker is aligned with some nefarious organization. The utterance also
helps guide the client toward a meaningful discussion of a key issue that
staff needs to discuss with himthe recommendation for placement in a
nursing home.
Proposed Strategy 5:Shifting Focus

Sometimes a client with psychotic symptoms is so caught up in a pattern of
delusional or disorganized thinking that the best strategy may be helping
the client shift attention away from the disorganized or delusional pattern
of thinking. An MI strategy termed shifting focus can be very helpful in
this regard. As Miller and Rollnick (2002) highlight, this strategy amounts
to going around the barrier to productive discussion rather than trying to
climb over it. It is important to note that when this strategy is applied in
an MI-consistent fashion, it typically involves first acknowledging the clients concern and then guiding the client to a discussion of a workable issue.
Without acknowledgement of the clients concern (be it reality-based or not),
this strategy has the potential to cast the provider in the expert role and the
client in a passive role.
Example:MI-Consistent/Inconsistent Shifting Focus
The following examples illustrate how a provider might use shifting focus in
an MI-consistent fashion to help a client who is stuck in a pattern of delusional or disorganized thinking.
MI-Inconsistent:Thats not really why Icalled you here today. Icalled you
here today because we need to talk to you about your medical issues.
This provider utterance is MI-inconsistent because the provider actively
dismisses the clients concerns and shifts to the topic of medical concerns in
a very non-collaborative fashion. This approach is likely to promote discord
between client and the provider or cause the client to assume a passive role
in the interaction.
Somewhat MI-Consistent:So youre still worried about your case worker.
What do you think we should do about that?
In this response the provider first reflects what the client has said and
then asks a question to gather more information. Thus, the response is
somewhat MI-consistent. However, what the provider chooses to reflect
and the question the provider chooses to ask focus the discussion on a
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topic that is not likely to lead to positive change. Since the case worker
is not really poisoning the client, developing solutions to that problem is
likely to have little benefit for the client and may increase the intensity of
his delusional beliefs.
MI-Consistent:You dont feel like a nursing home is going to be the best fit
for you, and youre questioning the case workers motive for recommending it.
What are the important things you are looking for in a place to live?
This provider utterance is MI-consistent because the provider acknowledges the clients concerns using reflective listening. Note that the provider
empathically reflected the clients concerns without agreeing either implicitly or explicitly that he is being poisoned or that his case worker works
for them. The provider then uses an open question to help shift focus to
a workable, but related issue:what characteristics the client looks for in a
place to live.
Proposed Strategy 6:Stacked Questions

Martino et al. (2002) recommend simplifying open questions for clients with
schizophrenia. Specifically, they recommend avoiding complex open questions
such as, What do you think your family would think about the nursing home
and how does that impact your willingness to consider it? A complex open
question such as that can be difficult even for very high functioning individual
with no cognitive impairments. I (JS) remember a time when a grand rounds
speaker in our department was asked a compound open question, and as one
might expect, she responded to the first part of the question and then had to ask
the questioner to repeat the second part of the question because she had forgotten it. For clients who have problems with organizing their thinking, these types
of questions can be very confusing and overwhelming. Simple phrasing of open
questions, such as:What do you think your family would think about the nursing home? [Waits for client response]. How does that impact your willingness
to consider a nursing home? are likely to be much more effective.
It has been our experience that even when phrased simply, clients with cognitive impairments such as disorganized thinking may have some difficulty
responding to open questions. Sometimes, even with a simple open question, the
client may feel unsure of what is being asked. The use of stacked questions can
help clients who have difficulty responding to simple open questions. Asking the
client an open question followed by a series of closed questions intended to give
the client a sense of what types of answers would address the open question can
be useful in this situation. This has been referred to as stacked questions (Moyers
etal. 2010)and is useful because it gives a client the confidence and certainty to
respond to an open question without narrowing the focus in the way a closed
question does.
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Example:MI-Consistent/Inconsistent Stacked Questions

The following examples illustrate how a provider might use stacked questions to help a client who is having difficulty responding to open questions.
MI-Inconsistent:Poisoning you? Are you sure? There isnt any evidence for
that is there, Roger?
This provider utterance includes stacked questions, but is not MI-consistent.
All of the questions are a direct confrontation of the clients statement. This
diminishes the clients sense of autonomy as well as the sense of collaboration in the interview. Additionally, the questions keep the focus on the
delusional content, instead of trying to guide the client toward a more productive discussion of the pressing issue at handhow the client would like
to handle his need for greater medical care than the board and care home
can provide.
Somewhat MI-Consistent:What do you want to do? Do you want to go to
the nursing home? Or do you want to see if your sister will let you move in
with her?
This response is somewhat MI-consistent. The provider starts off with an
open question that invites the client to share his preferences. By asking what
the client wants, the provider also offers some support for client autonomy
by expressing that what the client wants matters. However, instead of providing the client with a menu of possible ways to answer the open question, the closed questions that follow the initial question serve to narrow the
range of possible answers to the question.
MI-Consistent:What benefits might there be to moving somewhere like a
nursing home? For example, wouldnt it be nice to have people available 24-7
when you arent feeling well? Would it be good to be somewhere closer to your
family? Would you feel less anxious if you had your own room rather than
having to share?...
This provider utterance is MI-consistent because the provider asks an open
question to gain the clients perspective. Even though the open question is
followed by closed questions, the intent of these questions is to provide the
client with clarity about the spirit of the providers question as well as the
sense that there are a range of right answers to the question that has been
posed. This may enhance the clients ability and confidence to provide a
meaningful answer to the question and thus collaborate actively with the
provider in exploring the pros and cons of an alternative housing situation,
such as a nursing home.

Challenges Related to Psychiatric Symptoms
Clinical Challenge
Depression:
Hypothetical Questions:Hypothetical questions invite

a client to consider the possibility of change without
committing to it. These questions can help clients who are
feeling hopeless consider potential solutions or benefits of
change, even if they are currently feeling pessimistic about
the possibility of change.
Clients suffering
from depression
experience
hopelessness,
feelings of
worthlessness or
guilt, difficulty
concentrating, and
lack of interest in
activities that may
make it difficult for
them to fully engage
with a provider or
change process.
Planning:Planning involves helping a client think

through the concrete details of how desired change will
be accomplished. Aconcrete plan may help clients who
are feeling pessimistic become more hopeful about the
possibility of change.
Envisioning:Envisioning involves asking a client to
imagine what the future would be like if they were to make
a change. This strategy may be helpful for clients who
respond to questions about past negative consequences
of their behavior in an overly self-deprecating fashion
because they are experiencing excessive guilt or feelings of
worthlessness.
Affirming:Affirmations, which involve commenting on a
clients strengths or abilities in any area, can help clients
experiencing feelings of worthlessness or guilt to view
themselves as capable of change.
Summarizing:Frequent summaries of key points in the
conversation may enhance engagement for clients who have
difficulty concentrating.
Handouts:Providing clients who have difficulty
concentrating with MI-consistent handouts, such as a
decisional balance or change plan, may help them better
remember key points covered during a conversation about
change.
Looking Back:Asking a client to think about what things
were like before their depression emerged can help clients
who currently lack interest in activities to identify activities
they might enjoy or find rewarding.
(continued)
Table 6.5.CONTINUED
Clinical Challenge
Anxiety:
Empathic Listening:Listening carefully to a client in an

attempt to really understand his or her perspective may help
a provider to fully appreciate that the distress associated
with anxiety and related disorders is more than the
nervousness we all experience in certain situations.
Clients diagnosed
with anxiety or
related disorders
may avoid
essential aspects of
treatment, including
appointments
with their
provider, because
participating fully
in treatment causes
anxiety or distress.
Assessment Feedback:Providing clients with objective

feedback on an anxiety assessment may help clients better
recognize the ways in which anxiety and related disorders
are impacting their lives.
Evocation:Using evocative questions to help a client
articulate his or her reasons for change may help a client
who has not been fully participating in an intervention
due to anxiety develop sufficient motivation to endure the
intervention despite their anxiety.
Offering Choices:Offering the client choices about
intervention options available to him or her enables the
client to choose the intervention option that is best for him
or her all things (including anxiety) considered.
Emphasizing Control:Emphasizing that the client is the one
who ultimately has to choose what he or she will or will not
do may help empower a client who is avoiding treatment
due to anxiety or related disorders to actively engage in
treatment despite their distress.
Planning:Clients who may avoid treatment due to
symptoms of anxiety or related disorders may benefit from
making a plan for what they will do if they find themselves
considering avoiding an appointment or other treatment
activity.
Envisioning:Helping a client envision what treatment can
be like may be helpful to clients who suffer from anxiety or
related disorders and underestimate how difficult treatment
might be given their symptoms.
Psychotic Symptoms: Giving Information:Before attempting to utilize

MI-consistent strategies with an individual suffering from
Clients who
psychotic symptoms, it can be helpful to give information
experience
about the type of conversation you are hoping to have with
symptoms
the individual. Many MI-consistent strategies are so unlike
of psychotic
typical communication strategies that they might lead to
disorders including
confusion or uncertainty without this preface.
disorganized
Clinical Challenge
thoughts, speech,
and behavior, as
well as delusions,
may have difficulty
actively participating
in many types of
interventions.
Asking Permission:Asking permission to discuss

a particular topic may a useful strategy for guiding
disorganized clients back to the topic of discussion each
time the discussion veers off topic.
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Summarizing:Using summaries may be helpful when

working with clients who have disorganized thinking. With
a summary the provider may help the client organize his or
her thoughts in a meaningful way.
Reflective Listening:Providers may use reflections to
selectively emphasize reality-based content embedded
within a delusional client utterance.
Shifting Focus:Aprovider may use an open question to
shift the focus from a tangential or delusion topic to a topic
that is more likely to guide the client in the direction of
positive change.
Stacked Questions:Some clients with thought disorders
may be uncertain how to respond to open questions.
Following an open question with a series of closed questions
that seek to clarify the intent of the question for a client may
be helpful for clients who feel uncertain of how they should
respond to the open question.
In our own work, we have found that the principles and practices of MI can be
very fruitfully applied to some of the unique challenges encountered when working with clients who are experiencing psychiatric symptoms or disorders. These
challenges include things such as hopelessness, lack of interest in activities, difficulty concentrating, avoidance, and disorganized or delusional thinking. Given
that psychiatric illnesses are very common, mental health professionals are not
the only ones likely to encounter these unique challenges. Thus we attempted to
provide practical, non-technical descriptions of these symptoms and disorders
so that nonmental health providers can more readily identify clients who may
benefit from referral to mental health treatment and who may also benefit from
MI-consistent strategies to help them overcome barriers to change introduced by
their psychiatric illness. Asummary of these strategies can be found in Table 6.5.
Working with Multiple Individuals

Up to this point we have discussed clinical challenges related to working with
one individual. However, many providers work with multiple individuals
simultaneously. This work may take the form of seeing a couple about marital
issues or parenting, providing education to a group of clients, or facilitating
disorder-specific treatment groups. Working with more than one person in an
MI-consistent way requires simultaneously attending to a variety of concerns
and client factors. Thus, the MI-consistent provider needs to attend to things
like ambivalence, change talk, sustain talk, and discord as they uniquely apply to
each individual. It is likely that these variables are different for each person. In
other words, a provider cannot assume that there is a shared level of ambivalence among all clients involved in an interaction. Moreover, even if all clients
are experiencing an equal level of ambivalence, this will be experienced differently by each individual. However, the MI-consistent provider must avoid simply
doing individual MI for each person. Thus the question becomes, how does the
provider consider each individuals goals, ambivalence, and needs in the context
of working with multiple individuals? Furthermore, how does the provider balance these various goals and needs to keep the interaction moving forward?
As a means of helping you consider how to address this challenge, we present
two unique clinical challenges related to working with multiple individuals
working with parents and working with groups. We want to emphasize that our
focus in this chapter is on how to address challenges that arise when working
with parents and groups in an MI-consistent way. We are not, however, providing guidance on developing MI-based interventions for parents or groups.
C L I N I CA L C H A L L EN G E 1:PA R EN TS
Description
We have many colleagues who work with children and offer behavioral parent training as part of their clinical services. These colleagues frequently tell us
about their struggles to engage parents in parent training, especially when they
expect that their child will be the only one meeting with the provider and making
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changes. Although it is important to consider parent preferences in selecting an

intervention strategy for child behavior problems, our colleagues often express
that working with only the child will result in sub-optimal outcomes. In fact,
multiple approaches to addressing child behavior problems, including parent
training, tend to be the best approach (Curtis, Ronan, & Borduin, 2004). For
example, parent training programs are among the most robust, empirically supported interventions available for preventing, and even reversing, development
of antisocial behavior in youth (Kazdin, 2005; Maughan, Christiansen, Jenson,
Olympia, & Clark, 2005). Awide range of positive outcomes have been associated
with parent training programs including reduced behavior problems, increased
social competence, and improved academic performance among children.
Positive effects for participating parents also have been demonstrated, including improved parent-child relationships, reduced parenting stress, and reduced
use of corporal punishment (e.g., Nicholson Fox, & Johnson, 2005). Thus, from a
provider perspective, parent training programs would in many cases be considered an optimal first-line approach to addressing child behavior problems.
While parent training programs are promising, engaging parents in parent
training programs and reducing attrition rates is difficult (Sterrett, Jones, Zalot,
& Shook, 2010). Parents participating in parent training classes or interventions are most often seeking services because of a perceived (and often, actual)
child behavior problem such as noncompliance or aggression. In parent training
classes, the focus is on the parent as the agent through whom change in the child
is facilitated, which may be difficult for parents, who are focused on the child,
to accept. This creates a discrepancy between the parents and the provider as to
what the problem is and how to address the problem. As discussed in chapter2
discrepancies between clients and providers are likely to produce discord and
increase client sustain talk. Complicating the situation, discrepancies between
parents about the degree to which they need to learn different parenting skills
may exist. One parent may see the need to change her parenting skills whereas
her partner may see no need to learn new skills. Thus, the couple is not on the
same page in relation to what needs to be changed, and this may hinder engagement and retention in parent training. In these two situations it might be helpful to consider that one or both members of the couple are pre-contemplative
about their need to change their parenting practices. Adopting an MI-consistent
approach to discussing the option of parent training may help to address the
common pitfalls in parent training.
Example:Margo and Phil have an 11-year-old son, Benjamin. Benjamin has
been referred to a behavior specialist by his endocrinologist to better manage his diabetes. Benjamin was diagnosed with type 1 diabetes 2years ago
and it has worsened in the past 6months. Upon meeting Benjamin and his
parents, the behavior specialist learns that Margo and Phil disagree on how
much they need to monitor and manage Benjamins adherence to his medical treatment plan, including his diet. Margo will often monitor Benjamins
diet and ensure he is taking his medications. On the other hand, Phil believes
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that Benjamin is old enough to monitor these behaviors. Phil also believes
that Ben should be able to be a normal kid and often allows Benjamin to
eat whatever he wants. Thus, Benjamin often abides what his father says and
rarely manages his behavior in relation to his health. This behavior has led
to a worsening of Benjamins diabetes to the point their physician has become
concerned.
This example is not uncommon when parents bring their children for assistance with behavioral concerns. Parents may not have made the association
between their behavior and their childs behavior. Using some of the following
MI strategies may help parents make this link without becoming defensive and
ultimately help their child develop healthier behaviors.
Proposed Strategy 1:Providing Feedback and Information

Often parents are less aware of how their behavior or parenting practices may
have contributed to the development and maintenance of their childs behavioral problems. One approach to addressing this lack of awareness is to provide parents with information about how multiple factors, including parenting
practices, influence a childs behavior and the problems displayed. For instance,
the Family Check-up is an MI-based approach that includes feedback and has
empirical support (Brennan, Shelleby, Shaw, Gardner, Dishion, & Wilson, 2013;
Smith, Dishion, Shaw, & Wilson 2013). Giving information is a valuable strategy
in MI, and it is how the information is provided that makes the strategy more or
less MI-consistent. In particular, it is important that the information-giving process is engaging and objective. Additionally, information would generally only
be offered after asking permission or being invited to share the information. In
relation to parenting, it seems important to offer information to clients in a fashion that attempts to minimize any defensiveness or perception of being blamed
for the childs problems.
strategies for giving information to clients who are ambivalent about engaging in parent training.
Client Statement:Margo tends to micromanage everything Benjamin does.
It seems like he needs more space to be himself and be a normal kid.
MI-Inconsistent:Well, Benjamin certainly is at an age where he needs to learn
to better care for himself. Kids typically learn self-management behaviors from
their parents and your doctor is concerned that you and Margo are not helping
Benjamin to better manage his diabetes. Often when problems like these happen, parents need to change some of their parenting strategies to help their child.
This statement gives the client some information about the connection
between child and parent behavior. The provider even supports the clients perspective a bit. However, the way in which the information is
provided is MI-inconsistent. The provider simply offers the information without asking permission, announcing or emphasizing personal
control in providing the information. There is a potential for the information to be received as blaming by the clients, which could increase
discord. Finally, the provider does not elicit the clients responses to this
information.
Somewhat MI-Consistent:You two are concerned about Benjamin and his
health and have different opinions about how to help him manage his behavior. If its okay with you, Id like share some information we know about children and managing health behavior. [Waits for client response]. One thing we
know is that it is important for mom and dad to have a shared perspective of
how to manage their childs behavior. Sometimes when parents modify their
behavior a bit, it has a remarkable effect on the childs behavior. Ive got a list
of strategies that will help you get on the same page.
This provider statement is somewhat MI-consistent because it empathizes and affirms the parents and elicits a response to the information
from both parents. The provider also asks permission and presents the
information in a non-expert role. However, after presenting the information about the importance of a shared perspective, the provider does not
elicit the reactions from each parent to the information before presenting
the list of strategies. As a result, the information-sharing process is less
engaging and may result in discord.
MI-Consistent:You two are concerned about Benjamin and his health. You
have different opinions about how to help him manage his behavior. If its
okay with you, Id like share some information we know about children and
managing health behavior. [Waits for client response]. One thing we know
from a professional perspective is that when mom and dad dont have a
shared vision of how to manage the behavior that the childs behavior can
become more problematic. Sometimes when parents modify their behavior a
bit it has a remarkable effect on the childs behavior. What do you two think
about this information?
The provider offers this information in a MI-consistent way. The provider begins by affirming the parents dedication and concern for their
child. Next, the provider reflects the discrepancy between the parents
view of the problem [and possibly solution]. This is done in a way that
doesnt side with either parent. Before offering information, the provider
announces that he would like to share information. The provider gives
the information in the third person, in the context of what is known in
the professional world versus specifically focusing on the parents, which
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170
can decrease perceptions of blame or defensiveness. Finally, the provider

elicits the reaction from the parents to this information.
Proposed Strategy 2:Exploring Goals/Values

Sometimes parents are less aware of how their parenting practices might have
an effect on their goals for their children. Provider-client discussions that
invite clients to share their goals for their children and how their behavior
facilitates or hinders achievement of these goals might help clients make key
connections on their own. Such discussions can also help parents begin to
consider what may need to happen to support the achievement of their goals
for their child. Arelated approach is to explore the parents values in relation
to caring for their children and compare how current behaviors are in line or
not with those parenting values. In MI these strategies are called exploring
goals/values.
Example:MI-Consistent/Inconsistent Exploring Goals
exploring of goals or values.
MI-Inconsistent:Yes, there seems to be a discrepancy between your perspective and Margos perspective on how to parent Benjamin. Your goals
for Benjamin are for him to be a healthy, independent boy, yet your differences of opinion on how to achieve that are keeping him from achieving
those goals!
These provider utterances are MI-inconsistent. Both utterances begin with
MI-consistent reflections of the difference of opinion between the parents.
However, the provider then assumes the expert role and draws connections
between these differences of opinion and the clients goals and values rather
than eliciting from the clients how their disagreements might be related to
their goals and values. The provider also blames the clients for their sons
problem by stating that their parenting behavior does not facilitate his
being healthy and independent. Whether or not this provider observation
is accurate, it is MI-inconsistent, because the provider is taking sides and
thus is likely to elicit defensiveness and discord.
Somewhat MI-Consistent:You and Margo have some differences of opinion in how to parent Benjamin, which seems natural. How should we work
toward resolving those differences?
The provider statement is somewhat MI-consistent. It acknowledges the
existing discrepancies between the parents perspectives and normalizes
171
the situation. The provider then asks an open question, which invites the
clients to share their perspectives. However, the specific question asked
focuses how to solve the problem, not exploring goals and values. Thus the
provider has jumped to planning before evoking the clients motivations
for change.
MI-Consistent: You two are dedicated to Benjamins health. At the same
time you have different perspectives on how best to help Benjamin. Iwonder
if we could take some time to discuss your goals for Benjamin. What are the
goals each of you have for him and his future? [Waits for clients to respond].
How might these goals relate to your perspective on what is best for him in
relation to helping him manage his diabetes?
MI-Consistent: You two are dedicated to Benjamins health. At the same
time, you each have different opinions on how to best help him. Perhaps we
can discuss some of your values as they relate to parenting. What are some of
your values as a parent? [Waits for clients to respond]. How do these values
relate to your approach to helping Benjamin manage his diabetes? How are
these values similar and different from your partners in relation to helping
Benjamin?
provider affirms that both parents are dedicated to the health of their son.
Additionally, the provider highlights, in a non-judgmental way, the discrepancy between the parents. Next, the provider elicits from the clients
their parenting values and how these values relate to their perspective on
parenting the child.
Proposed Strategy 3:Decisional Balance

Given that one or both parents may initially be at a precontemplative stage in
relation to the need to learn parenting skills or change their parenting practices,
it might be valuable to examine the pros and cons of participating in parent
training. If both parents are involved in the discussion, it is important to elicit
pros and cons from both parents. One approach is to encourage the parents to
collaboratively develop the list of pros and cons. Another approach is to ask
each parent to identify their individual pros and cons and facilitate a discussion
between the parents.
Example:MI-Consistent/Inconsistent Decisional Balance
decisional balance for parents.
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MI-Inconsistent: You feel Benjamin needs more space to become a normal kid. On the one hand, Iagree that there are benefits to giving children
space and letting them be normal. On the other hand, Ican see Margos
point that Benjamin may need structure from you to get his diabetes under
control.
The provider responds with a reflection that captures only part of the discrepancy that existsthe fathers perspective. The provider then offers his
or her own unsolicited opinion about the pros and cons of the fathers perspective rather than eliciting them from the clients. This may create the
impression that the provider believes his or her opinion is more important
than the clients and is likely to increase discord in the session.
Somewhat MI-Consistent: So the two of you have different perspectives
on how to help Benjamin. Perhaps we can talk about some of the benefits of
learning new ways you can help manage his behavior and some of the drawbacks of not learning new skills to help him.
The provider begins with a reflection that highlights the different perspectives of the parents. Further, the provider seems to be incorporating a decisional balance by eliciting the pro-change side of the argument. However,
the provider makes no attempt to explore the drawbacks of changing and
benefits of not changing. Thus the provider has fallen into the taking sides
trap. Additionally, within the context of two parents, the focus taken by the
provider can be perceived as siding with one of the parents, which could
elicit discord from the other parent.
MI-Consistent:Both of you are concerned about Benjamin and his healthy
development. You have different perspectives on how to best help Benjamin.
Perhaps we can talk through some of these differences by having each of
you discuss the pros and cons of learning additional skills to help Benjamin
improve his health. If it is okay with each of you, it might be helpful for us to
discuss your perspective on the drawbacks of changing and not changing and
the benefits of changing and not changing your behavior.
The provider demonstrates an MI-consistent approach in several ways.
The provider begins by affirming the parents dedication to the health
of their child. Further, the provider highlights that a discrepancy exists
between the parents. The provider also reframes the discrepancy by suggesting both parents are trying to best help their son. The provider then
facilitates the decisional balance by first asking about the clients staying the way they currently are. Next, the provider asks the clients about
potential change efforts. One important point is that the provider emphasizes the need for both parents to discuss their perspective. This avoids
a potential perception that the provider is siding with one or the other
parent. Finally, the provider avoids advocating for one side or the other
(i.e., changing or staying the same) which is an important feature of a
decisional balance.
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C L I N I CA L C H A L L EN G E 2:G R O U PS
Description
There is an increasing need for health and behavioral health providers to reach
larger groups of people, including at-risk populations (Kazdin & Blaze, 2011;
Prochaska & Norcross, 2010). An increasingly popular method to reach wider
populations is to use groups (Schneider Corey, Corey, & Corey, 2010). Using
groups, whether to address mental health or medical issues, or facilitate self-help,
allows providers to address common concerns among clients simultaneously,
build off strengths and experiences of multiple clients, and facilitate mutual support (Forsyth, 2011). When thinking of groups, you may envision people sitting
in a circle talking about their inner-most secrets, or a 12-step group where someone discusses his rock bottom and others discuss how they relate. Groups take
on many different formats ranging from process-focused groups, which emphasize personal exploration, to treatment groups for specific problems (e.g., cognitive behavioral group for social anxiety), to educational groups such as a group
for clients awaiting an organ transplant (Wagner & Ingersoll, 2013). Given the
increasing importance of groups to address a wide array of behavior and health
issues, providers are often in the position to facilitate a group. However, many
may not have the necessary training or experience, especially to integrate MI
into group work. Reflecting on our education and training as psychologists, we
recognize that we encountered little to prepare us for group work.
Our goal here is to discuss how you might use MI to address clinical challenges encountered in group work. Given the diverse applicability of MI, there
has been a proliferation of MI in group work. For instance, MI groups have
developed for at-risk adolescent alcohol and drug use (DAmico, Hunter, Miles,
Ewing, & Osilla, 2013), promoting adherence to HIV medication (Holstad,
DiIorio, Kelley, Resnicow, & Sharma, 2011), and reducing school truancy (Ena
& Dafiniou, 2009), to name a few. However, the concept of stand-alone MI
groups to facilitate behavioral change is relatively new. More often MI is integrated with other evidence-based change approaches like cognitive-behavioral
therapy and the research support is limited (Wagner & Ingersoll, 2013). Because
MI was developed with a focus on individual behavior change some aspects may
be more difficult to adapt to groups. If you are interested in learning how to conduct MI-based groups, we encourage you to read Motivational Interviewing in
Groups by Wagner and Ingersoll (2013) where this topic is addressed more fully.
Whether you have facilitated groups or not, you can likely appreciate that
working with a group of individuals is vastly different than working with a single individual. As such, there are unique challenges encountered when working with groups. These challenges range from having to simultaneously focus
on the needs and goals of multiple individuals, to more complex factors such
as interpersonal issues between group members and members being at different stages of engagement in the group. Schneider Corey and colleagues (2010)
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outlined several challenges and problem behaviors that group leaders may face
in facilitating a group. These challenges, which will be the focus of our discussion, include intrapersonal concerns and interpersonal difficulties in the group.
Intrapersonal Challenges
Individuals enter a group with their unique expectations, goals, and personal characteristics that will impact their overt and covert group behavior.
Internally clients may have concern about their referral to the group, worry
about group involvement, differing readiness to engage in a group and change,
varying knowledge of the topic, and distinct apprehension about how they
will relate to and be treated by other group members (Schneider etal., 2010).
The task for the group leader related to these challenges is how to address
clients variability so that the group proceeds as a meaningful and valuable
experience for all clients.
Example: Kayla is a nurse practitioner. As part of her work in a transplant clinic, she facilitates an education group for individuals newly diagnosed with liver disease. Because it is an educational group, she focuses on
lecturing about liver disease and the transplant process. During a recent
group, she noticed various responses from her clients in relation to the
group. Tabitha focused on every word that Kayla said and took copious
notes; however, she often seemed confused but never asked questions.
Thomas did not seem to be paying attention. Jacob seemed to become
increasingly anxious as she talked about the different topics. Stacy, a client who works as a pediatric nurse, acted as though she didnt need to be
at the group and was bored by it. Kayla was worried as she didnt think
the group members were interacting well with each other or learning the
important information needed to help them manage their disease and
treatment.
Kaylas experience is often encountered when facilitating groups, especially
educational groups. What her experience highlights is the various intrapersonal challenges that might influence the development and functioning of the
group. As discussed throughout this book, one of the values of MI is fostering engagement among clients. Young (2013) demonstrated how the spirit
and principles of MI, discussed in c hapter2, align well with developing group
cohesion and goals. Further, Rollnick, Miller, and Butler (2008) discuss some
strategies that might be helpful for making educational groups more engaging. As educators we recognize how easy it can be to fall into lecture mode
and try to be cognizant of how to remain MI-consistent when educating and
facilitating group interactions inside or outside the classroom. Here are some
MI strategies that can be used to address some of the intrapersonal challenges
in facilitating groups.
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Using evocative questions in group work can help a provider engage group
members, avoid the expert trap, and establish a group environment focused on
understanding the unique needs of each group member. Evocative questions are
especially important for groups that have a specific focus, such as education or a
structured treatment for a particular disorder (e.g., exposure group for obsessive
compulsive disorder). Using evocative questions can help establish the norm of
open discussion in the group.
evoking for groups.
MI-Inconsistent: Welcome to the living with liver disease group. How long
have you had liver disease? Has anybody been to a group before? Who thinks
this group will be helpful? Does anyone want to learn how improve their health?
These questions are MI-inconsistent because they are closed questions
and are unlikely to facilitate clients opening up and engaging in discussion. Members of a group who are uncomfortable or uncertain about the
group experience could easily respond with minimal answers. Some of
these questions also could have a judgmental quality to them and could
increase discord and withdrawal from clients, which is the opposite of what
MI-consistent providers would want. Also, asking closed question after
closed question could close off clients as the provider has succumbed to the
question and answer trap.
Somewhat MI-Consistent:Thank you for coming to the living with liver disease group. What are the difficulties related to living with liver disease?
This statement is somewhat MI-consistent in that the provider provides an
affirmation for the group and asks an open question. However, the provider
falls into the premature focus trap by asking about the problems associated
with living with liver disease. In a group setting, this premature focus could
lead to discord and reduced involvement among the group.
MI-Consistent:Thank you for coming to the living with liver disease group.
Im sure some of you are unsure about this groupboth what to expect and
what is expected of you. That is natural. What are your expectations and
concerns about this group?
This statement is MI-consistent for several reasons. First, the provider affirms
the clients attending the group by thanking them for coming and normalizes
that clients have expectations and concerns about the group. Rather than
asking a closed question or jumping into education, the provider asks an
open question to elicit expectations and concerns from the clients. In doing
so the provider expressed her desire to learn about the clients, value for open
communication, and hope that clients are engaged in the group.
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Proposed Strategy 2:Discussing Pros and Cons of Group Work

Group members will likely be at various stages of readiness to engage in group
work and to make the types of changes the group is intended to facilitate. Many
have different expectations and concerns about the group, as well as diverse
knowledge and experience with groups. Discussing the pros and cons of group
involvement can help clarify for both the provider and the clients what the
unique expectations, hopes, and concerns of a particular group of clients may
be. When working with groups, providers will likely encounter shared and distinct pros and cons for each client. Thus, it is important for providers to ensure
that each client has the opportunity to offer pros and cons, and this may require
specifically asking a client or two to share.
Example:MI-Consistent/Inconsistent Discussing of Pros and Cons
discussion of the pros and cons of group work.
Client 1 Statement:I am not sure that this group will help. All Ineed is a
transplant!
Client 2 Statement:I dont knowI guess we could learn some things that
may help.
MI-Inconsistent:It sounds like folks might have various perspectives about
the value of this group. Let me take a little time now to tell you how this group
can help each of you live better with your liver disease.
The provider begins by highlighting the different perspectives expressed
by group members using a reflection. However, rather than exploring the
clients perspectives on the pros and cons of the group, the provider begins
to offer her own opinion about the pros of the group. She has fallen into
the expert trap with this response by implying that her perspective is more
valuable or valid. By focusing only on the pros, she also fell into the trap of
taking sides, which is likely to elicit anti-group responses from the clients.
Somewhat MI-Consistent:You all are probably concerned about what will
best help you with your liver disease. If it is okay with you, Id like to provide
some information on why the transplant team thinks these groups are important for all transplant candidates. Then Id love to hear your perspectives at
the end of the group.
This statement is somewhat MI-consistent. The provider acknowledges that
group members have ideas or concerns about how the group can be helpful, which expresses empathy. She also introduces the option to address
any questions or concerns at the end of group and asks permission to share
information, both of which somewhat enhance a sense of collaboration.
However, by tabling the discussion of client concerns to the end of the session and setting the agenda for the session without any client input, the
provider is assuming the expert role. This may enhance disengagement and
discord among those who are uncertain about the group.
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MI-Consistent: You all are probably concerned about what will best help
you with your liver disease. Also, each of you likely have different thoughts on
how this group may or may not help you. That makes sense given that you are
unique individuals and want what is best for you specifically. Perhaps we can
discuss each persons thoughts about the drawbacks and benefits of his or her
own participation in the group. Tabitha, what are your thoughts about that?
This provider statement is MI-consistent for several reasons. The provider
acknowledged that the clients are seeking what is best for them, thereby conveying a desire to collaborate with each group member. Next, the provider
commented on the fact that each group member may have different opinions
about the value of the group, normalizing these differences and emphasizing
autonomy. Finally, the provider facilitates the discussion by asking about the
pros and cons of participation in the group from each member, thus avoiding
taking sides or defending the group, and communicates a desire for open
discussion that includes dissenting opinions among all members.
Proposed Strategy 3:Elicit-Provide-Elicit

Most groups will likely require a provider to give information about a disease/
disorder, specifics of an offense and legal issues, a treatment approach, group
rules and norms, or any of a variety of other topics. The elicit-provide-elicit
approach offers an MI-consistent and engaging way to share information with
group members. Using elicit-provide-elicit, a provider can also gain valuable
insight into what the group already knows or doesnt know about the topic
through the initial eliciting. In contrast to how this strategy was discussed elsewhere in this book, in a group context a provider attends to all group members
responses and ensures that all members had an opportunity to respond before
and after information is provided.
Example:MI-Consistent/Inconsistent Elicit-Provide-Elicit
elicit-provide-elicit in a group.
MI-Inconsistent: Lets begin today with talking about lifestyle changes in
relation to liver disease. Many people think that all they need is medical treatment or a transplant to improve their health. However, there are many lifestyle changes you all can make that can help improve your liver disease. In
fact, if you were to have a transplant there will be many behavior changes that
will be required of you. We will talk about all of these today.
This provider statement is MI-inconsistent and likely to elicit sustain
talktalk about not changing. The provider falls into the expert trap and
essentially lectures the group. The provider does little eliciting to gain the
clients understanding about liver disease or different changes that need to
be made. Similarly, there is no eliciting from the clients their reaction to the
information the provider offered.
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Somewhat MI-Consistent: There are a lot of different things that go into

living with liver disease. Before we begin discussing these different things,
Iwould like to learn what each of you already knows about managing liver
disease. Who would like to discuss what they know about behavioral changes
in relation to living with liver disease? [Waits for clients responses]. Thank
you for your information. The biggest changes that people can make are to
stop drinking alcohol and take their medications. Does that make sense?
This statement is somewhat MI-consistent for several reasons. The provider
communicates empathy, acknowledging there are many things that require
change, and uses elicit-provide-elicit. However, the provider prematurely
focuses on making behavioral changes versus remaining less focused to
learn what group members already know, which could result in missed
information. Additionally, the provider asks who would like to share, a
closed question, versus explicitly stating she would like to hear what each
member knows. After providing information, the provider asks a closed
question that basically asks for agreement versus asking a question that is
more likely to elicit client reactions to the information.
MI-Consistent: There are a lot of different things that go into living with
liver disease. Before we begin discussing these different things, Iwould like to
learn what each you already know about managing liver disease. If it works
for you we can go around and each of you can share what you already know or
have heard about living with liver disease, because my bet is that each of you
have information you already know that you can discuss. [Waits for clients to
answer]. It sounds like you all have a lot of valuable information already. If
Imight add, one thing we might discuss is the different lifestyle changes, such
as stopping drinking and eating healthier, that can help you better manage
your liver disease. What are your thoughts about that?
This statement is MI-consistent because the provider communicates empathy and that there is a lot of information about living with liver disease
without talking about one specific aspect, thus avoiding the premature
focus trap. Additionally, before providing any information she elicits what is
known currently by the group and emphasizes her desire to hear from group
members. This communicates that the provider believes that each member
has important information about the topic and that she values hearing from
each of them. After the client responses, the provider reflects and reinforces
that the group knows a lot about the topic. She then announces that she
would like to provide information, gives the information, and then elicits
the group members reactions to the information.
Proposed Strategy 4:Group Planning

Thus far we have discussed planning as an MI-consistent strategy for working
with individuals; however, as discussed earlier, there are many differences in
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working with groups. One of those differences is that group members may have
different goals that they want to achieve. These differences may stall the progress of the group or interfere with the accomplishment of more general goals.
In c hapter 3 we discussed MI-consistent planning. With some adaptations to
account for multiple individuals, the planning process can be used to evoke from
group members their individual reasons and goals for involvement in the group
and then facilitate a discussion about developing group goals and outcomes.
Example:MI-Consistent/Inconsistent Group Planning
The following examples illustrate how a provider might use planning to
help group members prepare to successfully participate in a group.
Client 1 Statement: Im willing to try this group, but Im not really sure
about it.
Client 2 Statement:Yeah, this seems like a hoop we need to jump through to
get our transplant.
Client 3 Statement:I dont knowmaybe there are things we can learn to
make our lives better.
MI-Inconsistent:It sounds like some of you are uncertain about this group.
You are probably more interested solely in a transplant. Part of the process for
getting a transplant is to attend this group. Regular attendance is important
even if youre not sure about it. In this group we will discuss many things
including the transplant process, taking medications and lifestyle changes
before and after the transplant. It is a lot of information but we will most
likely cover something of interest to you.
The provider starts with a reflection to acknowledge the different perspectives of the group members. However, her next few statements could be perceived as confrontational and could elicit discord from the group members
who expressed concern about the group. Further, the provider is prescribing the plan for the group, neglecting to elicit any expectations or goals
from group members. The provider also assumes (instead of evoking from
clients) that the group will meet their goals in some way. Telling the client
what to do and assuming her plan will meet the various clients needs is not
collaborative, and may diminish the clients sense of autonomy or investment in the group.
Somewhat MI-Consistent: You all have different perspectives about this
group. Before we move any further, perhaps we can take some time to discuss
reasons for the group. [Waits for clients to respond]. There are a variety of
reasons for attending this group. So what should our plan of action be?
This provider statement is somewhat MI-consistent. The provider begins
with a reflection acknowledging that the group has different thoughts
about the group and attempts to elicit reasons for the group from members. However, the provider does not explicitly elicit from each member of
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the group. Additionally, the provider attempts to elicit a plan but may miss
important ideas from members with such a global question versus eliciting
from each member.
MI-Consistent:I am hearing that you all have different perspectives about
how the group may or may not meet your needs. This seems natural to me as
each of you knows what things tend to work best for you. Before we move any
further, perhaps we can take some time to discuss your individual reasons for
coming to the group. [Waits for clients to respond]. There are certainly various
important reasons for attending this group ranging from getting a transplant
Table7.1.Group Planning Form
Group PlanExample
The most important individual reasons why we want to participate in group are:
1. So Ican live better with liver disease
2. So Ican get a transplant
3. So Ican learn more about my disease
4. So my wife stops nagging me
Our group goals are to:
1. Better understand liver disease
2. Learn about the transplant process
3. Better understand medication
4. Become more self-sufficient in our disease
For group to be successful we must:
1. Attend meetings regularly
2. Respect each others opinions
3. Openly discuss our opinions and reactions in group
4. Participate in all group learning activities
Some things that could interfere with group success include:
1. Lack of participation of all members
2. Disrespect for differences of opinion
3. Disinterest in some aspects of group
We can help each other be successful by:
1. Providing encouragement
2. Providing reminders about group goals
What we will do if we are not sticking with group the way we had hoped:
1. Remind each other why we are attending group
2. Support each other
3. Remind each other of how the group has already helped
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to learning about lifestyle changes that can help you live with liver disease.
Now that we know why each of you is attending the group maybe we can talk
a bit about our collective plan for getting the most out of this group?
This provider utterance is MI-consistent. It begins with a reflection acknowledging and validating the different opinions of group members. Next, the
provider elicits the various reasons for attending the group, reflecting and
reinforcing the various reasons. Finally, the provider introduces the idea
of developing a group plan to make the group valuable for each client. This
approach is validating and collaborative, and the plan developed will likely
be more salient to the group members. As with the other strategies for
working with groups, the provider attends to each group member to ensure
that he or she is involved. You could also use the form in Table 7.1 to guide
group planning. Rather than giving the form to each individual member,
you could use the questions as a guide and present them using a dry erase
board, blackboard, or flip chart. You could also elicit volunteers from the
group to assume scribe duty and write the answers for the group on the
board or chart.
Interpersonal Difficulties
A group consists of multiple individuals, each with their own histories, personalities, idiosyncrasies, styles of communication, and pet peeves. Thus, interpersonal difficulties seem natural and to be expectedsort of like sustain talk
and discord. One role of a group facilitator is to build interpersonal cohesion
and manage these difficulties (Wagner & Ingersoll, 2013), and MI-consistent
strategies may be particularly useful (Young, 2013). Schneider Corey and colleagues (2010) identified several problem behaviors that often occur in groups
that are presented in Table 7.2. Some approaches to group facilitation suggest
that you directly challenge these behaviors and encourage group members to
do the same. The first task in MI-consistent responding to these behaviors is to
view them from an MI perspective as naturally occurring discord. Reframing
them from problem behaviors to discord can be a signal that something needs to
change in focus or discussion or interaction approach of the group. You can use
of some of the proposed MI strategies for interpersonal difficulties that follow to
help manage some of these behaviors ingroup
Example: John is a substance abuse treatment counselor who facilitates
12-member cognitive behavioral treatment groups at a community-based
intensive outpatient substance abuse treatment program. In his current
group, John has identified several clients that seem to be disrupting the group
process. Steve is a very active participant, and John values his contributions
and enthusiasm. However, Steve seems to monopolize a great deal of group
time, leaving little time for other clients to share their thoughts and feelings.
Additionally, Steve often makes comments or asks questions that are not
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Table7.2.Group Problem Behaviors

Behavior
Description
Monopolizing
A group member taking up the majority of group time and

talking about her or his concerns.
Off-topic
discussions
A group member routinely diverting the discussion away from

the topic of discussion.
Hostility
One group member responds in a passive or overtly aggressive

fashion to another.
Acting superior
A group member may respond condescendingly or in a

fashion that suggests he is better than the others.
Socializing
Group members engaging in side conversations or engaging

the group in social discussions that are not group related.
Adapted from Schneider Corey etal., 2010.
consistent with the topic John is trying to cover. Shari seems generally disengaged from the group, and John has observed her rolling her eyes or making
sarcastic comments under her breath as other group members ask or respond
to questions. It has become apparent that Shari believes she is not as bad off
as the other group members and questions whether she can benefit from the
group. Finally, Trisha, Bob, and Sarah frequently whisper and giggle among
themselves, or pass notes to one another during group. John notes that those
around them seem unsettled by their socializing during groups.
Proposed Strategy 5:Shifting Focus

Sometimes discord, such as that illustrated in this example, may be the result of
the discussion topic. For some approaches to group therapy (e.g., process-oriented
groups) challenging the discord is encouraged. However, that is MI-inconsistent.
In MI, discord is an indicator of a need to change something. One strategy is to
shift the focus away from what may be causing the discord. However, it is important to first acknowledge the group members behavior and others responses
before shifting the focus to avoid communicating you are uncomfortable with
what happened in the group and that group members cant openly express themselves. This approach can also be used if an individual is monopolizing group time
to shift the focus of discussion away from the monopolizing member to others.
Example:MI-Consistent/Inconsistent Shifting Focus
The following examples illustrate how a provider might use shifting focus in
an MI-consistent fashion to manage discord in a group.
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Client Statement: Im different than you all. I dont use bad drugs, I just
drink alcohol.
MI-Inconsistent:Lets not talk about whose drug use is better or worse. Lets
discuss how our drug has affected our lives.
This provider utterance is MI-inconsistent, because the provider dismisses the concern communicated by the client in relation to the group
and adopts an expert role. The providers response is also likely to raise
more discord as it could be perceived as challenging. The response has the
potential to make the client more passive rather than more active in the
group.
Somewhat MI-Consistent:Thanks for sharing. In what ways has drug and
alcohol use affected your lives?
This statement is somewhat MI-consistent as the provider acknowledges the
client statement in a non-confrontational way and shifts focus. However, the
provider avoids acknowledging the discord statement from the client, which
may invalidate the clients concerns and communicate that dissenting opinions are not valued in the group. The result of this statement is that the client
could disengage from the group and become less motivated to change.
MI-Consistent:You are concerned about the different types of substances
used by the group members. We may be getting a bit ahead of ourselves in
discussing the drugs used, and Iwonder if we could talk about what each of
you is hoping to gain from this group.
The provider begins by using a reflection to acknowledging the clients concern but doesnt agree or disagree with it. The provider then shifts the focus
of the discussion away from the differences in drugs used to a discussion
about what each member wants from the group. This could also transition
into a discussion about group rules and norms.

Reflective listening is at the heart of MI and can be used at any time in an
MI-consistent interaction. In groups, reflective listening can serve multiple
purposes (Wagner & Ingersol, 2013). First, the group leader can use reflective
listening to respond to interpersonal difficulties. By responding reflectively the
provider models alternate ways group members can respond to others in the
group. Second, the provider can facilitate group members responding to each
other using reflective listening.
The following examples illustrate how a provider might use reflecting to
manage interpersonal difficulties in a group.
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drink alcohol.
MI-Inconsistent:This is a common misconceptionalcohol is also a drug.
This statement is not a reflection and is MI-inconsistent. The information
the provider gives is accurate, but it is a direct confrontation of the clients
statement. This could facilitate expressions of resentment or hostility from
other group members who feel put down by the clients statement.
Somewhat MI-Consistent:You only use alcohol.
This statement is a reflection and is somewhat MI-consistent. The provider validates the concern of the client and resists the righting reflex.
However, this simple reflection is unlikely to move the conversation forward in a useful direction. Thus, although not wrong, with this response
the provider is missing an opportunity to engage other group members,
elicit more about the clients concerns and discord, or shift the focus to a
topic that is more likely to facilitate change.
MI-Consistent: Youre not convinced you belong in this group because you
use only alcohol.
This provider reflects the clients disagreement about their involvement in
the group, which is MI-consistent. However, the provider does not indicate
that he agrees or disagrees with the statement or directly confront the clients belief. He simply communicates that the provider is hearing what the
client has communicated. Choosing to reflect this particular aspect of what
the client has said is also likely to help shift the discussion to fruitful topics
such as the different treatment needs and goals of each group member.
MI-Consistent:I hear what you are saying about your involvement in the
group. At the same time Iwonder what others in the group are hearing you
say. Perhaps each of you can reflect back what you have heard. [Waits for each
member to respond]. Thank you for your responses. Maybe you can reflect
back to the group what you heard in their various responses.
The providers response is MI-consistent as he is attempting to facilitate a
discussion using reflective listening. The provider acknowledges hearing
the client. Next he prompts the other group members to reflect back what
they hear in the clients statement. The provider affirms the members for
their responses and invites the client to reflect back to the group what he
has heard.
Proposed Strategy 7:Eliciting Group Member Strengths

There can be a tendency when clients in a group experience interpersonal difficulties with one or more other members to focus on others negatives. Providers
can attempt to minimize interpersonal difficulties by eliciting strengths and
positive assets from group members who are having difficulties.
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Example:MI-Consistent/Inconsistent Eliciting of Group Member

Strengths
eliciting of group member strengths.
drink alcohol.
Client 2 Response:Who are you to talk? Your situation is worse than each
of us!
MI-Inconsistent:Okay, Im going to jump in here as this is not appropriate
group behavior according to our rules.
This is statement is a common one in facilitating groups with the goal of
reminding members how to participate in the group and to keep the discussion from escalating. However, the provider is assuming an expert role and
is also judgmental by labeling the behavior as inappropriate. Although in
some groups this might be a suitable response, especially to reinforce group
rules and behavior, it is MI-inconsistent.
Somewhat MI-Consistent:You two seem to be heading in a direction that is
concerning to me. If its okay with you, lets step back for a moment and talk
a bit about what strengths we see in each other.
This provider statement is somewhat MI-consistent as it is not as confrontational as the first statement and the provider expresses his concern.
However, the provider interrupts the discussion without asking permission. The provider only shares his perception of the situation and does not
elicit the perceptions of other group members. Finally, the provider includes
other group members in the discussion of positive qualities, making the
situation solely about the two group members.
MI-Consistent:If its all right with the group Iwould like to jump in for a
minute. You two seem to be heading in a direction that is concerning to me
and Iwonder how others feel about it. [Waits for others to respond]. Iwonder
if we can step back for a moment and talk a bit about what strengths we see in
each other and how that helps the group meet our goals.
This provider statement is MI-consistent for several reasons. First, the provider asks permission to jump in to the discussion versus interrupting. The
provider then shares his perception of the situation and asks for the perceptions of others in the group. Finally, the provider elicits from the group
to comment on the strengths of each member and also how each member
helps the group move forward.
In this chapter we presented the clinical challenges of using MI with multiple

individuals. Working with multiple individuals presents unique challenges for

Challenges Related to Multiple Individuals
Clinical Challenge
Parents:
Giving information:Providing information in an

engaging and objective fashion about the nature of the
childs behavior and the relationship between parenting
and child behavior change.
Differences between
parents in relation to
problem definition,
motivation for change, Exploring goals/values:Elicit from parents their
parenting goals, values, and goals for the child and
and ideas for change
contrast them with parenting behavior.
Decisional balance:Facilitate decision making among

parents by eliciting pros and cons about changing
from both parents with the goal of developing shared
motivation to change.
Intrapersonal
challenges in groups:
Individual factors and
behaviors that may
slow the development
and progression of the
group.
Evocative questions:Using questions aimed at genuinely

understanding about the group to engage each member in
the group.
Exploring pros/cons of group work:Engage participants
in a discussion about the benefits and drawbacks of the
group to address differences in readiness to change,
motivations, and concerns about the group.
Elicit-provide-elicit:Before providing information,
elicit from all members what they already know about
a topic and elicit reaction to the information from all
members after providing it. This can be used to reconcile
differences among group members.
Group planning:Engaging the group in determining
shared goals and methods to reach those goals within the
group. It is important to develop some consensus among
group members.
Interpersonal
challenges in groups:
Shifting focus:Acknowledging the discord in the group

and shifting focus to a less discord-evoking topic.
Behaviors displayed
by or between group
members that affect
the cohesion and
functioning of the
group.
Reflective listening:Use of reflection to highlight

the meaning in group members comments either
by commenting or eliciting reflections from group
members.
Eliciting strengths:Asking group members to comment
on the positive attributes and strengths of other members
with the goal to reduce discord.
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using MI as different people may have different levels of motivation, reasons for
changing or not, and perspectives of the concern/problem. Therefore, we emphasized throughout the chapter the importance of attending to these factors for
all individuals involved in the session and demonstrated how you may achieve
this with parents and groups using different MI strategies. While we did not
specifically discuss MI groups, we invited you to envision how MI can be used
to address intra- and interpersonal difficulties you may encounter when working with groups of people. In particular we encouraged you to be cognizant of
applying MI strategies to the entire group versus one or two individuals. Many
of the strategies we proposed can help you remain MI consistent while including
multiple individuals and their perspectives. Table 7.3 summarizes the clinical
challenges and suggested MI strategies.
Challenges in Learning to Use

and Implement MI
As discussed in c hapter 1, MI is not easy to learn. Most of the strategies and
concepts presented in this book sound deceptively straightforward and intuitive.
In fact, MI-consistent strategies are counterintuitive for many we have trained,
especially in the situations in which they would be most useful (e.g., when clients are angry or upset, have limited motivation to change, or disagree with the
provider). In this chapter we provide a number of tips that we have found useful in our own development as MI providers, applied in the MI trainings we
have provided, and learned as MI researchers. Through these various experiences with MI we have learned valuable information from our trainees, clients,
and participants that has solidified our appreciation for the nuances of learning
MI. In many ways, our process has paralleled how Dr.William Miller developed
his appreciation and understanding of MI (Adams & Madson, 2006). Thus, we
offer these tips for your consideration as you begin to develop or strengthen your
utilization of MI. As part of this discussion we also focus in greater detail on two
challenges in learning to use MI:provider feelings of frustration and provider
personal experiences that are similar to client experiences.
T I P 1:S E T R E A L I ST I C E X PECTAT I O N S
Many providers and students enter MI training with unrealistic expectations

about the ease with which they will learn MI. This is probably based in part on
the fact that many providers believe the practices they implement with clients are
actually far more MI-consistent than they actually are (Miller, Yahne, Moyers,
Martinez, & Pirritano, 2004). Whatever the source of the unrealistic expectations, they can result in disappointment and frustration during and following
MI training.
Miller and Moyers (2006) observed that there eight separate tasks or stages
involved in learning to successfully implement MI:(1)relinquishing the expert
role and opening oneself to truly collaborating with clients; (2)developing skill
Learning to Use and Implement MI
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in client-centered counseling, including accurate empathy; (3)recognizing and

selectively reflecting change talk; (4)eliciting and increasing change talk; (5)managing discord; (6)engaging in MI-consistent change planning; (7)consolidating
client commitment; and (8)integrating MI with other intervention styles. For
some providers, particularly those with training in methods of psychological
counseling or psychotherapy, the spirit of MI and the client-centered counseling aspects of MI may come relatively easy. In contrast, the more advanced and
less familiar aspects of MI, such as recognizing and reinforcing change talk as
well as eliciting and strengthening change talk, may come much less naturally.
For providers from disciplines with training, practices, and philosophies that are
less compatible with MI, all aspects of learning MI may present more of a challenge (Schumacher, Madson, & Nilsen, 2014). As noted in chapter1, for many
providers (including mental health providers), intensive workshop training followed by five sessions of coaching may be insufficient for expert competence or
even beginning proficiency in MI to be obtained (Madson, Schumacher, Noble,
& Bonnell, 2013; Miller etal., 2004; Moyers etal., 2008; Schumacher, Williams,
Burke, Epler, & Simon, 2013; Smith etal., 2012). In fact, for many, learning proficient use of MI parallels the process (e.g., practice, observation and coaching)
many providers undertook to learn how to practice in their disciplines.
We strongly recommend that providers and students set expectations that
match the amount of MI training they will receive. Based on experience, if a provider is able to receive workshop training, plus up to 20 feedback-based coaching
sessions, it seems highly likely that he or she will achieve expert competence in
MI (Schumacher etal., 2013). If a provider, like many providers we train, does
not have the time or resources to undertake that amount of training, he or she
may still learn some valuable practices and principles of MI that can enhance
work with clients. If a provider has not received any formal training in MI, but
would still like to figure out how to apply at least some of the practices and principles of MI to his or her daily work, this book was written with that provider in
mind. Although a novice provider is unlikely to be able to conduct a motivational
interview after reading this book, he or she should be able to implement select
strategies that may help better address common clinical challenges. However,
remember the value and importance of the MI spirit that we emphasized
throughout this book. Without adhering to the spirit of MI in implementing
these strategies, they will likely be implemented in an MI-inconsistent fashion.
T I P 2:B E O PEN - M I N D ED
Many providers come to our MI training with very strong pre-existing

beliefs about what types of strategies are best for a particular type of client (Schumacher etal., 2014). For example, many years ago, a fellow trainer
shared the story of a provider who had said of MI, this stuff probably works
for some clients, but some clients just need to be confronted. As elaborated
later in this chapter, it has been our experience that in fact the clients who
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are viewed as most appropriate for MI are often those who need it the least
and vice versa. Other providers may draw seemingly premature conclusions
about whether or not MI works on the basis of one or two attempts at using
MI (often attempts that are not particularly MI-consistent). What we always
encourage is that if a provider is considering adopting MI, he or she must keep
an open mind. MI is not a panacea, that is, it will not be the solution for every
client who is struggling with issues of motivation. But MI is also quite different from practice as usual (Miller & Rollnick, 2009), and is something that few
providers (except those with extensive training in MI) just naturally implement in their day-to-day conversations with clients. We remember our early
sessions attempting to implement MI. In the beginning we were uncertain
about whether MI worked, because our implementation of the practices and
principles was not yet expert. However, we also remember the first sessions
when we really got it and clients seemed to almost miraculously move from
just considering change (contemplation) or even not considering change at all
(precontemplation) to fully committed to change and ready to act on a change
plan (Prochaska & DiClemente, 1983). If providers are considering adopting
MI (or select MI strategies), we encourage them to try it with their most challenging clients, the ones they are certain will only respond to confrontation.
We also encourage them to try it repeatedly (not just once or twice) before
drawing conclusions about whether or not it is a style that they would like
to make part of their repertoires. We think it is important to remember the
advice of Dr.William Millerlearn the same way Idid, from your clients
(Adams & Madson, 2006p.104).
T I P 3:G E T O B J ECT I V E FEED BAC K
As noted, individuals who are attempting to learn MI are generally not very good
at gauging how MI-consistent their work is. Although in general, providers tend
to overestimate how MI-consistent their performance is (Miller etal., 2004)we
have also observed, especially among more self-critical trainees, an underestimation of how well they are performing. It is hard to imagine how a provider
could improve their performance in implementing MI-consistent strategies, if he
or she did not know how well they were currently implementing the strategies.
Thus, getting objective feedback is generally recommended for anyone who is
hoping to learn to implement MI (e.g., Miller etal., 2004). It has been our experience that providers perceive great benefits of receiving objective feedback and are
very reluctant to submit work samples or allow observation of their practice so
they can receive objective feedback. Interestingly, as we have conducted research
to improve how we do MI training, one option we considered was not requiring
work samples. We noted, as had many others, that providers were very reluctant
to comply with requests to provide work samples for coaching (e.g., Schumacher,
Madson, & Norquist, 2011; Schumacher et al., 2012). To test this assumption,
we informally surveyed providers we had trained about the perceived value of
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getting feedback on work samples. Much to our surprise, even among groups of
trainees who had shown great reluctance to submit work samples for feedback,
responses were uniformly supportive of this practice.
Motivational Interviewing Trainer Tips
Set realistic expectations
Be open-minded
Get objective feedback
T R A I N I N G C H A L L EN G E 1:C L I EN TS W H O
FR U ST R AT E YO U
Description
In MI training we deliver to providers who are already in practice (i.e., not students), those who attend the trainings will often describe de-identified examples
of clients they see. The clients that providers discuss most frequently are those
with whom they have a long-standing relationship. Sometimes they will discuss
long-standing positive relationships with clients. These relationships are generally characterized by the client attending all appointments, following the providers guidance, and speaking positively about their experience with the provider.
In our experience, these cases are often discussed as examples of either (1)how
the provider has already successfully used MI to motivate change in the past, or
(2)a client for whom the provider believes MI would work. Closer examination
of the first case often reveals that the client was highly motivated for change at
the outset of his or her interactions with the provider, and it was this intrinsic
motivation that helped foster a long-standing positive relationship rather than
MI. Remember, MI is not practice as usual and it is highly unlikely that a provider without training in MI is actually practicing MI (Miller & Rollnick, 2009).
Closer examination of the second case often reveals that the client who is perceived as the perfect MI client actually does not need MI at all; he or she has
sufficient intrinsic motivation to implement provider recommendations and/or
develop and follow through on his or her own plan for change without MI.
More commonly, providers who attend our trainings will discuss clients with
whom they (and sometimes the entire staff at a facility) have a long-standing
negative relationship. From their perspective, the water that has passed under
the bridge in these long-standing relationships is littered with missed appointments, requests for special treatment, non-compliance with recommendations,
disruptive behavior, and so on. These clients are often presented as a challenge to the MI systemclients who cannot possibly benefit from MI and for
whom a more confrontational, directive, and possibly even punitive approach
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is necessary. Although MI is not a panacea (Miller & Rollnick, 2009) and is

not a guaranteed solution to every problem with every client, closer evaluation
of these cases often reveals a pattern of provider-client interactions that may
serve to entrench rather than reduce discord and sustain talk (Moyers, Miller
& Hendrickson, 2005). From the client perspective, the water under the bridge
in these long-standing negative relationships is often littered with lack of understanding, improper treatment (long wait times, insufficient time with a provider,
rude staff), unsolicited advice, confrontation, and/or direct orders. Whatever the
cause, long-standing negative client-provider relationships seem to be a source
of significant frustration to providers. The following example illustrates a case in
which a long-standing relationship may elicit frustration from a provider.
Example:Bob is diagnosed with a serious mental illness and has been a client
at a community mental health center on and off for approximately 20years.
Over those 20years the staff has seen Bob cycle through good periods when
he takes his medications and attends other services such as counseling and
vocational rehabilitation, and bad periods when he does not take his medication or follow other recommendations. During these bad periods Bob
often ends up homeless or in jail. These bad periods are often very disheartening and frustrating to providers. It is also frustrating to providers that when
Bob returns to the community mental health center for services after one of
these bad periods he does not openly discuss what they perceive as the central cause of his recent misfortunehis lack of compliance with treatment.
Instead he complains that his case manager is never available to drive him to
doctors appointments or to help him get his benefits check.
Providers we train and work with also describe encounters with clients who
seem to enter the client-provider relationship with a chip on their shoulder.
These clients may perceive that they have been mistreated (by the facility at
which they are seeking service, their family, the criminal justice system, life circumstances, other providers, etc.), believe that the interventions offered are not
appropriate or sufficient for their specific needs, or have other issues that lead to
immediate or almost-immediate discord between client and provider. This can
be very frustrating to providers who enter the relationship with optimism and a
sincere desire to help. (The unique challenges presented by clients who have been
forced to participate in an intervention are addressed further in chapter4). I(JS)
vividly recall an occasion when another providers client came to the reception
area of my office stating that he had a question about his medication and was told
Iwas the person to ask. Being a psychologist (who doesnt prescribe), Iwasnt
sure how Icould be helpful, but knew that the young man had misconceptions
about my role in his treatment that needed to be clarified. As soon as we had
found a confidential location to discuss his concerns, Iwas immediately accosted
with very loudly voiced accusations that Ihad withheld medication from him.
By using the spirit and strategies of MI, I was able to de-escalate and clarify
the situation and, most importantly, avoid feeling frustrated or intimidated by
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this client. The following example illustrates a client with whom a provider may
experience immediate frustration.
Example: After an hour in the waiting room, Rachel is called back to the
exam area for her prenatal visit. After a nurse takes her vital signs and walks
her to an exam room, she refuses to enter the room, stating, You are just
going to make me wait here again. Iknow Im not a doctor, and Iknow this
is a free clinic, but my time is valuable and Ideserve some respect. After the
nurse finally convinces Rachel to enter the exam room and have a seat on the
exam table, Rachel proceeds to answer the nurses questions about her health
since the last visit with curt and hostile sounding replies.
Proposed Strategy 1:Affirmation List

As described in c hapter2, during an MI session affirmations are used primarily
to help clients see their strengths, resources, and previous successes from which
a change effort may build. However, in our years of providing training to various
audiences, we have come to identify another potential use for affirmationsto
help providers see clients strengths, resources, and previous successes, thereby
reducing their frustration. In frustrating interactions with clients, whether the
relationship is long-standing or brand new, we have observed that many providers seem to make what social psychologists have termed the fundamental
attribution error (Ross, 1977). The fundamental attribution error describes the
tendency of people to underestimate the impact of situational factors on others
behavior and to overestimate the impact of dispositional factors. We infer that
many providers may make this error in thinking about the clients who frustrate
them, because of what they tell us about those clients:he just doesnt want to
change, you just cant talk to people like that, she came in with a chip on her
shoulder. It could also be inferred from what they fail to mention to us about the
client or his or her situation:she has had to wait at least an hour in the waiting
room for every visit, his medications cause terrible side effects, or he has had
12 different case managers assigned to him over the last 20years.
The foundational spirit of MI, as noted in chapter2, requires not only evocation (of change talk), but also collaboration, acceptance, and compassion. Thus
feelings of frustration and the negative thoughts about a client that likely accompany those feelings are impediments to MI practice. To help those we train,
coach, and supervise overcome this common barrier to MI practice, we have
found helpful to first ask them to list at least five (and ideally more) strengths or
accomplishments that describe this client before discussing MI-consistent strategies that might be used. By focusing on the characteristics or accomplishments
of a client that are worthy of affirming, provider perspectives of a client often
shift and they are better able to be collaborative, accepting, and compassionate.
In turn this spirit of collaboration, acceptance, and compassion better allows
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providers to see the role that situational factors (sometimes including the providers own behavior!) may have played in eliciting non-adherence, complaints,
or hostility from the client. With this fresh perspective, providers are often able
to more effectively identify and apply other MI strategies to help clients move
toward positive change.
Example:MI-Consistent/Inconsistent Affirmation List
The following examples will illustrate how to identify when you are frustrated with a client (like Bob or Rachel) and might benefit from developing
an affirmation list, as well as how the list might look. You will notice that
these examples differ from many of the other examples in this book as they
do not represent sample dialogue between a provider and a client. Rather,
they represent examples of what a provider might say to themselves or to
another provider about a client.
MI-Inconsistent:Bob needs to take responsibility for his own mental health.
He is in complete denial about his mental illness. He comes in here with such a
strong sense of entitlement; he thinks case managers are like personal assistants.
MI-Inconsistent:Rachel is a hostile person. She has no right to treat people
that way and if shes not careful shes going to cross the line and get kicked out
of this clinic. What does she expect from a free clinic, anyway?
This type of thinking about a clienta list of weaknesses, liabilities, and
deficitsdoes not foster MI spirit and makes it very hard for a provider to
apply other MI strategies that might promote change.
Somewhat MI-Consistent:We need to find someone to take Bob to pick up
his benefits check.
Somewhat MI Consistent:Rachel struggles with long wait times.
The first example illustrates a provider thinking about a client in a way that
shows compassion and a desire to help. However, it also suggests the provider is thinking of the client as a passive recipient of services who needs
staff to do for him, rather than an autonomous person capable of collaborating in his own care. The second example illustrates a provider who
is thinking about a client in a somewhat but not fully empathic and supportive fashion.
MI-Consistent:Bob has really shown perseverance. Despite the ups and
downs of the past 20 years, he keeps coming back and trying to make
changes in his life. He has also been very patient with usI know these
case management changes have been confusing and frustrating to him. He
also knows a lot of what he needs to get back to health and stability, regular
medical care, regular income, and so on.
MI-Consistent: Youve got to admire Rachels dedication to her baby. She
doesnt come from a social circle that really supports the importance of prenatal care, and the wait times people experience when they receive services here
would try anyones patienceand yet she keeps coming back.
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This type of thinking about a client or creating a list of strengths and accomplishments fosters MI spirit and makes it much easier for a provider to apply
other MI strategies in a manner that will help promote positive change.
T R A I N I N G C H A L L EN G E 2:C L I EN TS L I K E YO U
Description
If youve lost 10 pounds, does that make you an expert on weight loss? What if
youve lost 50 pounds? What about 100 pounds? If you used to have an alcohol
use disorder and have been sober for 20 years, does that make you an expert
on recovery? If you were a youth offender and turned your life around, does
that make you an expert on offender rehabilitation? From an MI perspective,
the answer would be:yessort of. it makes you an expert on how you successfully lost weight, stopped drinking, or turned your life around. And, if you are
a weight loss counselor, an addiction counselor, or work in the juvenile justice
system, there will undoubtedly be clients who will benefit from the wisdom of
your personal experience. However, there will also undoubtedly be clients whose
best strategy for weight loss, sobriety, or rehabilitation looks almost nothing
like the strategy you successfully used to achieve those goals. In order to be
MI-consistent in your approach to helping others, it is important to remember
that in each interaction with a client there are two experts in the room:the client
is an expert on his or her situation, values, preferences, etc. and the provider is an
expert on how others (including possibly the provider himself) have successfully
achieved changes in their lives (Miller & Rollnick, 2002).
Our experience in providing MI training is that many undergraduate students, graduate students, and professionals of all types are inclined to assume
that the strategies that have worked for them will work for others. This is true
in real play exercises in which participants in our trainings partner-up and
take turns discussing changes they are considering and practicing MI skills. The
changes discussed in these real play exercises are often typical, everyday changes
that most people have tried to make; things like reorganizing a closet, starting
an exercise program, or watching less television. It is quite common, especially
during early practice exercises, for us to overhear comments such as, Have you
tried [strategy]? It worked for me! Participants often find themselves drawing
on their personal experience to advise their partner rather than sticking to the
use of MI skills.
We also observe this tendency in role-play exercises, case discussions, and
supervision sessions based on actual or role-played interactions with a client
who is considering a bigger life change, such as abstaining from alcohol use after
years of heavy drinking or better managing their blood sugar to get control of
their diabetes. We have observed that providers who had successfully made the
change being considered by their client often favored sharing the strategies that
had worked for them rather than eliciting from the client the strategies that he
or she believes might work best. Providers who had similar experiences also at
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times seemed to assume that the clients underlying motivations, hesitations,

and so on were identical to the providers. For example, during a case discussion, a provider presenting a client who repeatedly expressed the belief that substance abuse treatment was not the right place for him, because he was not as
bad the other clients, might say, I was just like him. Ithought Iwas so different
than everyone else. He just needs to get past that. Miller, Sorensen, Selzer, and
Brigham (2006) note that there is evidence that substance abuse treatment providers who are in recovery may be less open to varied perspectives on substance
abuse treatment, and the same may be true for providers in other areas who have
overcome the same problems their clients are facing.
To combat what seems to be a fairly common tendency to assume that having
had a similar personal experience gives us a unique understanding of the personal experience of our clients, we recommend using empathic listening strategies, particularly reflections and open questions. When beginning to implement
MI, it may be most important to intentionally use these strategies when you are
most certain that you understand the clients perspective. This will create opportunities to see firsthand that sometimes your assumptions are accurate and other
times they are not. In cases where you lack certainty, checking your assumptions
will likely come more naturally to you, and you probably wont have to be as
intentional about it.

In teaching the concept of reflective listening in MI, Miller and Rollnick (2013)
often refer to Thomas Gordons (1970) model of communication. In this model,
communication involves three processes: encoding, hearing, and decoding.
Encoding is the process whereby the speaker identifies what he or she wishes
to express and chooses words through wish to express it. Hearing, as you might
guess, is the process whereby the listener perceives the words uttered by the
speaker. Decoding is the process by which the listener infers the speakers meaning from the words he or she has heard. As Miller and Rollnick (2013) note,
there are three places where communication can go awry:(1)the speaker may
not clearly state what it was he or she hoped to express; (2) the listener may
not clearly hear what the speaker said; or (3)the listener may mistake what the
speaker meant by what he or she said.
Quick Reference
How Communication Can Go Wrong
Speaker doesnt say what he or she means.
Listener doesnt accurately hear what speaker said.
Listener misinterprets what speaker meant.
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From an MI perspective, reflective listening is about confirming that what a

listener thinks the speaker meant is what he or she actually meant. Thus reflective listening, when well done, can be very useful to help ensure that our assumptions about the ways in which our clients might be similar or different from us
are accurate.
Table 8.1 is an example of how we presented this model of communication
in a recent training session. As you review Table 8.1, imagine what would have
happened if Mike had gone with his assumptions about what I (JS) meant, rather
than using a reflection to check those assumptions. If he assumed I thought he
was angry, he might have wondered what he had done that would have made
me think he was angry. This in turn might have caused him to feel worried or
irritated. If he assumed I heard his stomach growl, then he might have felt selfconscious and embarrassed. Worst of all, if he hadnt clarified what I meant, I
might have missed the opportunity to try my first deep-fried tamale (if youre
ever in the Mississippi Delta, I highly recommend it).
The following examples will illustrate how to use reflective listening to
ensure you arent making assumptions about a client because he or she
seems similar to you.
Client Statement:I admit Ihave problems, but Idont need substance abuse
treatment. Everyone here is way worse than me.
MI-Inconsistent:Do you think you are different than everyone else here?
Although this question seeks to clarify what the client meant, it is not a
reflection and it is not MI-consistent. Closed questions such are often
Table8.1. Communication Model Example

Encoding Error
Julie Thinks:I wonder if Mike wants to grab lunch during the break.
Julie Says:Are you angry? (Instead of, Are you hungry?)
Mike Reflects:You think Im angry with you.
Hearing Error
Julie Says:Are you hungry?
Mike Hears:Are you angry?
Mike Reflects:You think Im angry with you.
Decoding Error
Mike Hears:Are you hungry?
Mike Thinks:Oh no, she must have heard my stomach growl.
Mike Reflects:You heard my stomach growl.
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perceived (and intended) as very confrontational, and thus are likely to

result in defensive responding from the client (Miller & Rollnick, 2013).
Somewhat MI-Consistent:You dont need substance abuse treatment.
This statement is somewhat MI-consistent. The simple reflection expresses
empathy, but is likely to result in either a simple yes or no response or
encourage sustain talk.
MI-Consistent:You think you are different than everyone else here.
This statement is MI-consistent because it seeks to clarify what the client
meant by his or her statement. The client is likely to respond by either correcting the provider if that is not what he or she meant or further exploring
the ways in which he or she is different from and perhaps similar to the
other clients in the treatment program.
Proposed Strategy 2:Open Questions

Open questions are another great way to test assumptions you may have about
a client. When it comes to testing your preconceptions about a client, often
the most important open question to ask is the one of which you feel certain
of the answer. A classic example of this is in the Miller and Rollnick (1998)
Motivational Interviewing:Professional Training Series videos. In one of the case
examples in this series, John, who was referred from his employer subsequent
to a positive drug screen, notes that if he had kids he might have to rethink his
drug use. To this, Dr.William R.Miller responds, And why would you do that?
Seems like an obvious, almost senseless question. Everyone knows that it isnt
good for parents to use drugs, right? But drawing on the communication model,
the MI provider is always aware that he or she might be surprised (perhaps very
surprised) by the answer. John might have said, Drugs cost money, and if Ihad
kids Id need to spend the money on the kids. Or he might have revealed, Ive
had two prior arrests for drug possession, the next time Iget caught, Im going
to prison for sure. You just cant do that to kids. Or he might have said, My
parents were heavy drug users and it really messed me up. Or he might have
said any number of other things. By asking John an open question, Dr.Miller
not only creates an opportunity for John to voice his own reasons for change (a
central goal in MI), but also creates an opportunity to test any assumptions he
might have about Johns reasons for change based on his own experience as a
parent or the experience of countless clients with whom he has worked over the
years. Dr.Miller also avoids the potential discord that can result from erroneous assumptions. For example, if Dr.Miller had assumed that Johns objection
to parental drug use was a moral one (e.g., everyone knows parents shouldnt
use drugs) when in fact it was a practical one (e.g., I think it is fine for parents
to smoke marijuana, the problem is that its illegal in this state, and Idont want
my kids to suffer from the legal consequences.), John would likely have felt
judged and discord would have emerged.
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Example:MI-Consistent/Inconsistent Open Questions

The following examples will illustrate how to use open questions to ensure
you arent making assumptions about a client because he or she seems similar to you.
Client Statement:I admit Ihave problems, but Idont need substance abuse
treatment. Everyone here is way worse than me.
MI-Inconsistent:Do you think you are different than everyone else here?
This question is not an open question, it is a closed question. It is also
MI-inconsistent because it is like to be perceived by the client (and possibly
be intended by the provider) as a direct confrontation of the clients assertion that he doesnt need treatment. This is likely to increase discord in the
interaction.
Somewhat MI-Consistent:In what ways are others worse than you?
This open question is somewhat MI-consistent in that it invites the client to
elaborate. However, it invites the client to elaborate on why others are worse
than the client. This is sustain talk and is unlikely to help the client move
toward change on the problems he or she does have.
MI-Consistent:So you have problems, but you arent sure this is the right
place for you. Tell me a little more about the types of problems you have had.
MI-Consistent:So you arent certain this is the right place for you to solve
your problems. What would be helpful to you?
These provider utterances are MI-consistent. Both begin with a reflection
of the clients uncertainty about treatment. This is likely to reduce discord.
Then the provider uses open questions to gather more information about
the clients perspective. In the first example, the provider seeks to gain a better understanding of why the client perceives substance use as a problem.
In the second example, the provider seeks to gain a better understanding of
what type of treatment or assistance (if any) the client perceives he or she
needs to overcome the problem. Although the questions will give the provider very different information, both are likely to help the provider gain a
better understanding of this clients unique perspective.
S U M M A RY
In this chapter we provide tips for learning and implementing MI-consistent

practices in your daily work. We have found those who set realistic expectations, keep an open mind about the role of MI in their work, and get objective
feedback about their use of MI have the most positive training outcomes and
enjoyable training experience. We have also found two situations, summarized
in Table 8.2, that impede implementation of MI for many providers. The first
is clients with whom a provider feels frustrated. Intentionally focusing on the
strengths, achievements, and positive qualities of these clients seems to help
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Table8.2.Summary of Training Challenges

Training
Challenge
Clients who
frustrate you.
Affirmation lists:Developing lists of the positive qualities and

strengths of clients to shift focus away from perceived deficits.
Clients who are

like you.
Reflective listening:Use of reflection to better understand

and appreciate the meaning of the clients comments and
experience.
Open questions:Using open questions aimed at genuinely
understanding.
providers adopt the spirit of MI in their interactions with them. The second
impediment is a temptation to draw more heavily on the providers personal
wisdom and experience than the clients wisdom and experience when working with clients who are similar to the provider. Very intentional use of reflective listening and open questions may increase collaboration and support of
autonomy in these situations. We believe that the practices and principles of MI
are within everyones grasp. With practice and appropriate training, you can
achieve whatever level of expertise you believe is appropriate for your practice.
C O N C LU S I O N S
We hope you have enjoyed reading Fundamentals of Motivational Interviewing:

Tips and Strategies for Addressing Common Clinical Challenges. We also hope that
this book has provided food for thought on how the principles and practices of
MI might be applied to a variety of ubiquitous, but nonetheless frustrating, clinical challenges. MI is a powerful communication style that can facilitate positive
change in even the most seemingly hopeless situations. We have observed this
phenomenon directly in clients we have treated and participants in our research
studies. We have heard this feedback from providers we have trained and also
experienced the benefits of MI firsthand. We both look forward to opportunities
to participate in, as well as facilitate practice exercises, during the training we
provide. That is because, depending on the particular exercise, participation provides opportunities for us to discuss a change we are considering in our own lives
with a training participant who seeks to (1) empathically and collaboratively
reflect or evoke our desire, ability, reasons, need, and commitment to change;
and/or (2)affirm our strengths and past successes; and/or (3)help us develop a
realistic and personalized plan for change. Those opportunities, in turn, provide
a vehicle through which we develop or renew our motivation for changes in our
own livesfrom organizing a closet or file cabinet to healthy eating and regular
exercise.
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As noted in chapter1, the body of research on MI is growing at an incredible pace (Lundahl & Burke, 2009). Moreover, this research indicates that almost
invariably when MI is applied to clients experiencing a particular problem or
challenge, it helps facilitate positive changeand in many cases with a smaller
dose of an intervention (Burke, Arkowitz, & Menchola, 2003; Hettema, Steele,
& Miller, 2005; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Rubak,
Sandbaek, Lauritzen, & Christensen, 2005). However, it is also important to
note, that for many problems and challenges to which MI is applied, the research
support is still emerging. In those areas, we believe that MI is best applied as
an adjunct to approaches with a longer track record and stronger evidence base
rather than a stand-alone intervention. This book is designed to support this
adjunctive use of MI. In the course of practice-as-usual, a provider may apply the
relevant MI concepts, principles, and strategies described in this book as needed
to help overcome hurdles introduced by less readiness to change, loss of momentum, psychiatric symptoms, and working with multiple individuals. To do this,
however, we remind you of the importance of the MI spirit as a foundation for the
integration of MI with practice as usual! In fact, our discussions of MI-consistent
and MI-inconsistent applications of strategies often emphasized the importance
of the MI spirit in guiding the application of a particular strategy. Based on our
experience training others in MI we cannot over state this point.
In 1983, Dr. William R. Miller introduced an approach to helping clients
achieve positive life changes that can best be described as revolutionary. This
approach was elaborated by Dr.Miller and Dr.Steve Rollnick in 1991 with the
publication of the first edition of the Motivational Interviewing text. Since that
time, MI has been refined, studied, and practiced by countless others. We are
excited to be a part of this ongoing revolution and invite you, our reader, to see
for yourself how collaboration, evocation, acceptance, and compassion can help
your clients overcome the most difficult challenges they face on the path to positive life changes. Whether this book is the beginning of your development as a
MI-consistent provider or an addition to your MI library our hope is that we
have contributed to your understanding of MI and its application to challenges
faced in helping others change.
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ABOUT THE AUTHORS
Julie A. Schumacher, PhD, is an Associate Professor and Vice Chair for

Professional Education and Faculty Development in the Department of
Psychiatry at the University of Mississippi Medical Center and Director of the
Mississippi Psychology Training Consortium. She is actively involved in motivational interviewing practice, training, supervision, dissemination, and research
and has received multiple NIH grants for her work in this area.
Michael B. Madson, PhD, is an Associate Professor in the Department of
Psychology at the University of Southern Mississippi. He is actively involved
in training, supervising, and researching motivational interviewing as part of
health and harm reduction interventions. His work has been funded by multiple
agencies, including the NIH and the American Psychological Foundation.
INDEX
Page numbers followed by "f" and "t" indicate figures and tables.
Ability, 3536, 5051
Absolute worth, acceptance and, 19
Abstinence violation effect, 107
Acceptance, 1921, 146
Accurate empathy, 19
Action, transtheoretical model and, 12, 71
Activating, mobilizing statements
and, 37
Activities, lack of interest in, 136140
Adherence, 8081. See also
Non-adherent clients
Adolescents, 4
Advice, 5
Affirmations
acceptance and, 2021
depression and, 131132
engagement and, 44
frustrating clients and, 193195
overview of, 2728
Agendas, handouts and, 135
Agenda setting, focusing and, 46,
4748t
Aggression, 167
Alcohol prevention, 61, 6567t
Ambitions. See Expectations, overly
ambitious
Ambivalence
decisional balance and, 53
non-adherence and, 82
push-back and, 22
Amplified reflections, 31
Angry clients, 192
Anxiety
effectiveness in treating, 4
overview of strategies for, 164t
Anxiety, trauma-related, and obsessive
compulsive disorders. See also
Post-traumatic stress disorder
assessment feedback and,
143145, 145t
description of, 140142
empathetic listening and, 142143
emphasizing personal control and,
148149
envisioning and, 150153
evocation and, 145146
importance and confidence and,
102103
offering choices and, 146148
planning and, 149150
social anxiety, 141143
Appointment policies, 76
Approval, affirmations vs., 27
Assessment feedback, 143145, 145t
Autonomy
clients involved in legal system and,
9294
no-shows and, 7880
slow progress and, 100, 105106
Avoidance, anxiety disorders and, 140,
141142
216 I n d e x
BASICS. See Brief Alcohol Screening and

Intervention for College Students
Behavioral therapy, motivational
interviewing vs., 14t
Brief Alcohol Screening and
Intervention for College Students
(BASICS), 61, 6567t
Building motivation for change, 42
CAT acronym, 37
Challenging clients. See Frustrating
clients; Obstacles to learning
motivational interviewing; Similar
clients
Change plans. See also Planning
depression and, 134, 136
development of, 5758t, 5759
slow progress and, 100, 104105
Change Plan Worksheets, 5758t, 59,
150, 151t
Change talk
eliciting and responding to, 38
evoking and, 50
importance of, 29
overview of, 3537
slow progress and, 100
Choices, offering, 146148
Cigarette smoking, 4, 138t
Client autonomy. See Respect for client
autonomy
Client-centered therapy, motivational
interviewing vs., 1314
Clients, defined, 9
Closed questions, 2526
Coaching, 190191
Coaching sessions, 6, 189
Cognitive dissonance, 11
Cognitive therapy, motivational
interviewing vs., 14t
Collaboration, overview of, 1617
Collecting summaries, 3233
Commitment, mobilizing statements
and, 37
Communication, model of,
196197, 197t
Compassion, 2122
Complex reflections, 3031

Compliance, adherence vs., 8081
Components of motivational
interviewing, overview of, 16
Concentration difficulties, 132136
Concerns, asking permission to
provide, 118120
Confidence, 102104, 109111
Confidence rulers. See Scaling questions
Consolidating commitment to
change, 42
Contemplation, transtheoretical model
and, 12, 71
Control, personal. See Respect for
client autonomy
Corrections, use of MI for, 4
Courts. See Legal system
Criminal justice system. See Legal
system
DARN talk, 3536, 5051. See also
Ability; Desire; Need; Reason
Decisional balances
depression and, 134, 136, 138t
lapses and relapses and, 112113
motivational interviewing vs., 13
overview of, 53
parents and, 171172
Decoding, 196197
Definitions. See Terminology
Depression
affirming and, 131132
description of, 125
difficulty concentrating and,
132136
envisioning and, 130131
evidence for effectiveness in
treating, 4
feelings of worthlessness or guilt
and, 129132
handouts and, 134136, 137t, 138t
hopelessness and, 125129
hypothetical questions and, 126127
lack of interest in activities and,
136140
looking back and, 139140
Index
planning and, 128130

summarizing and, 133134
Desire, 35, 50
Diabetes control, 4
Discord
9496
groups and, 182
overview of, 3940
Disengagement, signs of, 43
Double-sided reflections, 3031
Eating disorders, 4
Effectiveness of motivational
Elicit-provide-elicit approach
groups and, 177178
overly ambitious expectations and,
121122
overview of, 55
Emotional well-being, 4
Empathetic listening, 142143
Empathy, accurate, 19
Empowering clients, 2425
Encoding, 196197
Engaging
BASICS example and, 65t
HUB City Steps example and, 62t
indications of successful, 45
overview of, 4245
road map and, 60t
Envisioning, 130131, 150153
Evoking
anxiety, trauma-related, and
obsessive compulsive disorders
and, 145146
groups and, 175
120121
overview of, 1718, 4953
road map and, 60t
217

Exchanging information, 5455. See
also Giving information
Expectations, overly ambitious
asking permission to provide a
concern and, 118120
elicit-provide-elicit and, 121122
overview of, 123t
training and, 188189
using evocative questions and,
120121
Exposure-based interventions,
140141
Family Check-up, 168
Feedback. See also Assessment
feedback
agenda setting and, 4748t, 49
and, 143145, 145t
parents and, 168170
training and, 190191
First impressions, 42
Focusing
groups and, 182183
overview of, 4549, 46t, 4748t
psychotic symptoms and, 160161
road map and, 60t
Foundational spirit, overview of, 1622
Four processes of motivational
interviewing. See Processes of
motivational interviewing
Frustrating clients, 191195, 200t
Fundamental attribution error, 193
Giving information
9092
no-shows and, 7577
118120
218 I n d e x
Giving information (cont.)

parents and, 168170
planning and, 5455
Goals, 44, 170171. See also
Expectations, overly ambitious
Gordon, Thomas, 196
Group Planning form, 180t
Groups. See also Multiple individuals
discussing pros and cons of working
with, 176177
eliciting group member strengths
and, 184185
elicit-provide-elicit approach and,
177178
evocative therapy and, 175
intrapersonal challenges and,
174181
intrapersonal difficulties and,
181185
overview of strategies for, 4, 186t
planning and, 178181, 180t
reflective listening and, 183184
shifting focus and, 182183
Guiding principles, overview of,
2225
Guilt, 129132
Handouts, depression and, 134136
HBA1c, 4. See also Diabetes control
Health promotion, 5961, 6264t
Hearing, communication and,
196197
High school counseling, 4
HIV risk behaviors, 4
Hopelessness, 125129. See also
Depression
Hostility, 182t
HUB City Steps, 49, 5961, 6264t
Hypertension, 5961, 6264t
Hypothetical questions, 126127
Importance, 102104, 109111
Importance-Confidence Scale, 51. See
also Scaling questions
Importance rulers. See Scaling

questions
Individuality, groups and, 174181
Inflection, reflections and, 28
Information exchange, 5455. See also
Giving information
Initiating discord. See Discord
Initiating rolling with resistance, 95
Interest, lack of, 136140
Intrapersonal challenges, 174181,
186t
Intrapersonal difficulties, 181185,
186t
Know Your Numbers cards,
4748t, 49
Lapses and relapses
eliciting and affirming strengths
and, 113114
giving information and, 108109
looking back and, 111112
overview of, 123t
reassessing importance and
confidence, 109111
reframing and, 114115
Learning. See Training
Legal system, clients involved in
autonomy and, 9294
initiating discord and, 9496
overview of, 97t
Less ready to change clients
involved in legal system, 8996, 97t
non-adherence, 8089, 97t
no-shows, 7280, 79t, 97t
overview of, 7172, 9698, 97t
Linking summaries, 3334
Listening to clients, 24. See also
Empathetic listening; Reflective
listening
Looking back, 111112, 139140
Looking forward, 8586
Index
Loss of momentum
lapses and relapses, 107115
overly ambitious expectations,
116122
overview of, 99, 122, 123t
slow progress, 100106
Maintenance, transtheoretical model
and, 12, 71
Mental illnesses, 4 , 124125, 165. See
also Anxiety, trauma-related,
and obsessive compulsive
disorders; Depression; Psychotic
symptoms
Menus of options
planning and, 5657, 56f
Meta-analyses, 34
Miller, William R., 3, 198, 201
Misconceptions about motivational
interviewing, 1215, 14t
Missed appointments. See No-shows
Mobilizing change talk/statements, 37
Momentum. See Loss of momentum
Monopolizing, 182, 182t
Motivation
change talk and, 35, 50
understanding, 24, 83
Motivational Interviewing in Groups
(Wagner and Ingersoll), 173
Motivational Interviewing:Professional
Training Series videos (Miller and
Rollnick), 198
Multiple individuals
groups, 173185
overview of, 166, 185187, 186t
parents, 166172
National Comorbidity Survey
Replication, 124
Need, 36, 51
Negative relationships, 191195
New Years Resolutions, 107
Non-adherent clients
219
emphasizing autonomy and, 8889

evocative questions and, 8283
looking forward and, 8586
overview of, 97t
revising change plan, discussing
options and, 8688
scaling questions and, 8385
No-shows
emphasizing autonomy and, 7880
motivational interviewing-consistent
referrals and, 7375
overview of, 97t
planning and, 7778, 79t
OARS acronym, 25. See also
Affirmations; Open questions;
Reflections; Summaries
Objectivity, clients involved in legal
system and, 9192
Obsessive-compulsive disorder. See
Anxiety, trauma-related, and
Obstacles to learning motivational
Off-topic discussions, 182t
Open-mindedness, 189190
Open questions
complex, 161
engagement and, 44, 45
overview of, 2527
preconceptions about clients and,
198199
Options
planning and, 5657, 56f
Parents
exploring goals and values and,
170171
providing feedback and information
and, 168170
220 I n d e x
Parent training programs, 167

Permission, asking for, 118120,
156157
Person-centered therapy, 11, 14t
Planning. See also Change plans
and, 149150
groups and, 178181, 180t
HUB City Steps example and,
6364t
no-shows and, 7778, 79t
overview of, 5459, 56f, 5758t
road map and, 6061t
Post-traumatic stress disorder (PTSD),
144, 145t
Praise, affirmations vs., 27
Precontemplation,transtheoretical
model and 12, 71
Preparation, transtheoretical model
and 12, 71
Preparatory change talk, overview of,
3536
Problem behaviors, groups and, 181,
182t
Processes of motivational interviewing
alcohol prevention example, 61,
6567t
engaging, 4245
evoking, 4953
focusing, 4549, 46t, 4748t
health promotion example, 5961,
6264t
overview of, 42
planning, 5459, 56f, 5758t
road map for, 59, 6061t
Process-focused groups, 173. See also
Groups
Project Match, 59
Pros and cons, 176177. See also
Decisional balances
Providers, defined, 9
Psychological illnesses. See Anxiety,

trauma-related, and obsessive
compulsive disorders; Mental
illness; Psychotic symptoms
Psychological well-being. See
Emotional well-being
Psychosis, defined, 153
Psychotherapy, motivational
interviewing vs., 1314, 14t
Psychotic symptoms
asking permission and, 156157
reflective listening and, 158160
shifting focus and, 160161
stacked questions and, 161162
summarizing and, 157158
Question and answer trap, 25
Questioning. See Closed questions;
Open questions
Quick fixes. See Expectations, overly
ambitious
Reactance theory, 88
Readiness rulers. See also Scaling
questions
depression and, 134, 135136, 137t
overview of, 5152
Readiness to change, 12, 71. See also
Less ready to change clients
Reason, 36, 51
Recycling, 99
Referrals, no-shows and, 7375
Reflecting change talk, 38
Reflections, 2831, 44. See also Complex
reflections; Simple reflections
Reflective listening
clients like you and, 196198
groups and, 183184
no-shows and, 78
psychotic symptoms and, 158160,
165t
Reframing, lapses and relapses and,
114115
Index
Relapse, 99. See also Lapses and

relapses
Relational component of motivational
interviewing, 16
Resentful clients, 192
Resistance. See also Discord
as a prior term for discord, 9495
Respect for client autonomy
and, 148149
9294
no-shows and, 7880
Reverse psychology, motivational
interviewing vs., 13
Reviews, overview of, 34
Righting reflex
compassion and, 21
defined, 22
depression and, 126
resisting, 2224
Road map for motivational
interviewing, 59, 6061t
Rogers, Carl, 11, 16
Rolling with resistance, 95
Rollnick, Steve, 201
RULE acronym, 22
Rulers. See Scaling questions
Scaling questions. See also Readiness
rulers
depression and, 127
overview of, 5152
Schizophrenia, 154. See also Psychotic
symptoms.
Schools, 4
Self-efficacy, 11
Shifting focus, 160161, 182183
Similar clients, 195199, 200t
Simple reflections, overview of, 2930
221
Skills, basic
affirmations, 2728
open questions, 2527
reflections, 2831
summaries, 3134
Slow progress
assessing importance and confidence
and, 102104
emphasizing personal control and,
105106
evocative questions and, 101102
overview of, 123t
revising change plan and, 104105
Smoking cessation, 4, 138t
Social anxiety, 141143
Socializing, groups and, 182t
Spirit of motivational interviewing,
overview of, 1622
Stacked questions, 161162
Strengths, eliciting and affirming,
113114, 184185
Summaries
engagement and, 44
overview of, 3134
Summarizing change talk, 38
Superiority, 182t
Sustain talk, 3839, 5253
Taking steps, mobilizing statements
and, 37
Technical component of motivational
interviewing, 16
Techniques, motivational interviewing
vs., 13
Terminology
definitions of motivational
interviewing, 1112
of mental illnesses, 124
overview of, 9, 11
Tone, reflections and, 28
Training
clients like you and, 195199
222 I n d e x
Training (cont.)
frustrating clients and, 191195
objective feedback and, 190191
open-mindedness and, 189190
overview of challenges in, 56,
188189
setting realistic expectations and,
188189
Transition summaries, 34
Transtheoretical model (TTM), 12, 71
Trauma. See Anxiety, trauma-related,
and obsessive compulsive
disorders; Post-traumatic stress
disorder
Treatment groups, 173. See also Groups

Trickery, motivational interviewing
vs., 13
TTM. See Transtheoretical model
Two-phase approach to motivational
interviewing, 42
Unfairness, 192
Values, 44, 170171
Work samples, 190191
Workshops, 56, 189
Worthlessness, feelings of, 129132

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Fundamentals of Motivational Interviewing

Oxford University Press 2015

Although initially developed and written about by Dr. William R. Miller as an

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

of numerous randomized controlled trials to draw more robust conclusions

findings for MI are always emerging and sometimes surprising, providers of MI

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Fundamentals of Motivational Interviewing:Tips and Strategies for Addressing

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

This book is intended as a resource for individuals interested in applying the

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Foundational Concepts and Skills

Motivational interviewing (MI) was initially described as a counseling

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

MI is a particular kind of intentional communication about change.

In 2009, Miller and Rollnick attempted to clear up several misconceptions about

Motivational Interviewing is Not Based on the Transtheoretical

Foundational Concepts and Skills

Motivational Interviewing Is Not a Way of Tricking People into

Motivational Interviewing Is Not a Technique

Motivational Interviewing Is Not Simply a Decisional Balance

Motivational Interviewing Is Not just Client-Centered Therapy or

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Table2.1. Comparison of Motivational Interviewing and Common

Level of direction Following

Length of contact Long-term

Motivational Interviewing Is Not Easy

Foundational Concepts and Skills

Motivational Interviewing Is Not an Answer for Everything

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

In 2009, Miller and Rose described a theory of how MI facilitates change

MI depends on a relationship between the client and provider that resembles a

Foundational Concepts and Skills

Traditionally, many behavior change approaches tend to focus on determining

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Foundational Concepts and Skills

Respecting Client Autonomy

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Foundational Concepts and Skills

clients willingness to keep his appointment is a strength and acknowledges

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

R:Resist the Righting Reflex

Foundational Concepts and Skills

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

This response is somewhat MI-consistent. The provider provides a nice

U:Understand the Clients Motivations

L:Listen to the Client

E:Empower the Client

Foundational Concepts and Skills

often made. While providers may be knowledgeable regarding specific aspects

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Have you been following your diet?

Foundational Concepts and Skills

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Foundational Concepts and Skills

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

engagement. The reflection communicates that the provider hears where

Foundational Concepts and Skills

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Foundational Concepts and Skills

M o tivati o n al I n t e rvi e wi n g Ov e rvi e w

Foundational Concepts and Skills

Examples of Preparatory Change Talk

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

Foundational Concepts and Skills

The Four Processes of MI

The Four Processes of MI

The Four Processes of MI

The Four Processes of MI

The Four Processes of MI

The Four Processes of MI

The Four Processes of MI